Healthcare Provider Details

I. General information

NPI: 1437408887
Provider Name (Legal Business Name): MATTHEW RANDOLPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 NW 60TH ST
GAINESVILLE FL
32607-2008
US

IV. Provider business mailing address

1502 W NC HIGHWAY 54 STE 103
DURHAM NC
27707-5572
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-5100
  • Fax: 352-332-9607
Mailing address:
  • Phone: 919-354-0840
  • Fax: 919-748-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9315572
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9315572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: