Healthcare Provider Details

I. General information

NPI: 1013211630
Provider Name (Legal Business Name): DANA MARIE RANDALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2010
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S 8TH ST 1ST FLOOR
PHILADELPHIA PA
19106-3519
US

IV. Provider business mailing address

235 S 8TH ST 1ST FLOOR
PHILADELPHIA PA
19106-3519
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-3493
  • Fax:
Mailing address:
  • Phone: 215-829-3493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA055363
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: