Healthcare Provider Details

I. General information

NPI: 1629018411
Provider Name (Legal Business Name): CARLA R RANDOLPH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PAUL BRYANT DR E
TUSCALOOSA AL
35401-2094
US

IV. Provider business mailing address

305 PAUL BRYANT DR E
TUSCALOOSA AL
35401-2094
US

V. Phone/Fax

Practice location:
  • Phone: 205-345-0192
  • Fax: 205-247-2194
Mailing address:
  • Phone: 205-345-0192
  • Fax: 205-247-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-267
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: