Provider Demographics
NPI:1962805952
Name:RANDALL, JOVAN MONIQUE
Entity type:Individual
Prefix:
First Name:JOVAN
Middle Name:MONIQUE
Last Name:RANDALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 PAGE MILL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-2073
Mailing Address - Country:US
Mailing Address - Phone:985-215-9041
Mailing Address - Fax:
Practice Address - Street 1:112 MAVERICK CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-1381
Practice Address - Country:US
Practice Address - Phone:985-215-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034690363LF0000X
FLTPAN3168363LF0000X
TXAP137273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily