Provider Demographics
NPI:1962832998
Name:CULLER, RANDALL THOMAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:THOMAS
Last Name:CULLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25865 BARTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3895
Mailing Address - Country:US
Mailing Address - Phone:909-668-3636
Mailing Address - Fax:909-558-3754
Practice Address - Street 1:25865 BARTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3895
Practice Address - Country:US
Practice Address - Phone:909-668-3636
Practice Address - Fax:909-558-3754
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51299363AM0700X
CAPA51299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical