Healthcare Provider Details

I. General information

NPI: 1306981378
Provider Name (Legal Business Name): RANDOLPH W HEATH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HEALTH PARK BLVD STE 1
ST AUGUSTINE FL
32086-5798
US

IV. Provider business mailing address

120 HEALTH PARK BLVD STE 1
ST AUGUSTINE FL
32086-5798
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-3401
  • Fax: 904-829-8649
Mailing address:
  • Phone: 904-823-3401
  • Fax: 904-829-8649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2170
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: