Healthcare Provider Details

I. General information

NPI: 1932110467
Provider Name (Legal Business Name): RANDOLPH WILLIAM KNOX PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAHC BAMBERG
APO AE
09139
US

IV. Provider business mailing address

1525 ALAMO AVE
COLORADO SPRINGS CO
80907-7303
US

V. Phone/Fax

Practice location:
  • Phone: 499513008619
  • Fax:
Mailing address:
  • Phone: 808-388-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA07845
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0005326
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: