Healthcare Provider Details

I. General information

NPI: 1467408690
Provider Name (Legal Business Name): JASON A RANDALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 W WARNER RD STE 23
CHANDLER AZ
85224-1674
US

IV. Provider business mailing address

2905 W WARNER RD STE 23
CHANDLER AZ
85224-1674
US

V. Phone/Fax

Practice location:
  • Phone: 480-345-2031
  • Fax: 480-491-2767
Mailing address:
  • Phone: 480-345-2031
  • Fax: 480-491-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3437
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3437
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3437
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: