Provider Demographics
NPI:1912949124
Name:RANDOLPH, GREGORY E (PA-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:E
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:309 2ND ST
Practice Address - Street 2:
Practice Address - City:GLADBROOK
Practice Address - State:IA
Practice Address - Zip Code:50635
Practice Address - Country:US
Practice Address - Phone:641-473-2707
Practice Address - Fax:641-473-2641
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA000693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAR80986Medicare UPIN
IA12585Medicare PIN