Healthcare Provider Details

I. General information

NPI: 1356781819
Provider Name (Legal Business Name): RANDAL HERBERT FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RANDY HERBERT

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14116 CUSTOMS BLVD
GULFPORT MS
39503-5164
US

IV. Provider business mailing address

4200 IOLA ST.
METAIRIE LA
70001
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-6300
  • Fax:
Mailing address:
  • Phone: 504-296-0777
  • Fax: 504-455-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0613731
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: