Healthcare Provider Details

I. General information

NPI: 1134647019
Provider Name (Legal Business Name): RANDALL JAMES LAW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S WOODRUFF AVE STE 9
IDAHO FALLS ID
83404-6371
US

IV. Provider business mailing address

2001 S WOODRUFF AVE STE 9
IDAHO FALLS ID
83404-6371
US

V. Phone/Fax

Practice location:
  • Phone: 208-419-3002
  • Fax: 208-656-5652
Mailing address:
  • Phone: 208-419-3002
  • Fax: 208-656-5652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1108
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberPA1797
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: