Healthcare Provider Details

I. General information

NPI: 1649686486
Provider Name (Legal Business Name): RANDALL OKOLICHANY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 05/14/2021
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 US 1
NORTH PALM BEACH FL
33408-4513
US

IV. Provider business mailing address

1372 SW KNOLLWOOD DR
PALM CITY FL
34990-1919
US

V. Phone/Fax

Practice location:
  • Phone: 561-840-1090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113556
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: