Healthcare Provider Details

I. General information

NPI: 1639626997
Provider Name (Legal Business Name): ADAM LEE RANDALL DNP, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2016
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 ARAIA DR
FOUNTAIN CO
80817-1590
US

IV. Provider business mailing address

7415 ARAIA DR
FOUNTAIN CO
80817-1590
US

V. Phone/Fax

Practice location:
  • Phone: 863-224-2903
  • Fax:
Mailing address:
  • Phone: 863-224-2903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number114971
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0992741-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: