Healthcare Provider Details

I. General information

NPI: 1235162892
Provider Name (Legal Business Name): PHYLLIS ELAINE RANDALL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CHARLES ST
PLEASANT VALLEY NY
12569-7703
US

IV. Provider business mailing address

35 HORSESHOE RD
MILLBROOK NY
12545-6028
US

V. Phone/Fax

Practice location:
  • Phone: 845-635-2650
  • Fax: 845-635-2433
Mailing address:
  • Phone: 845-677-9544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001537
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: