Healthcare Provider Details

I. General information

NPI: 1962832998
Provider Name (Legal Business Name): RANDALL THOMAS CULLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25865 BARTON RD SUITE 101
LOMA LINDA CA
92354-3895
US

IV. Provider business mailing address

25865 BARTON RD SUITE 101
LOMA LINDA CA
92354-3895
US

V. Phone/Fax

Practice location:
  • Phone: 909-668-3636
  • Fax: 909-558-3754
Mailing address:
  • Phone: 909-668-3636
  • Fax: 909-558-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA51299
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number51299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: