Healthcare Provider Details

I. General information

NPI: 1538410550
Provider Name (Legal Business Name): JESSICA LEUNG RANDALLS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 CROUCH ST
OCEANSIDE CA
92054-4415
US

IV. Provider business mailing address

605 CROUCH ST
OCEANSIDE CA
92054-4415
US

V. Phone/Fax

Practice location:
  • Phone: 760-736-7676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number016061
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: