Healthcare Provider Details

I. General information

NPI: 1760471932
Provider Name (Legal Business Name): RANDALL ALAN BISCHOFF RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MOUNT BELVEDERE BLVD
FORT DRUM NY
13602-5438
US

IV. Provider business mailing address

11050 MOUNT BELVEDERE BLVD
FORT DRUM NY
13602-5438
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-4025
  • Fax: 315-772-4025
Mailing address:
  • Phone: 315-772-4025
  • Fax: 315-772-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000092
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: