Healthcare Provider Details

I. General information

NPI: 1134616733
Provider Name (Legal Business Name): RANDALL MATTHEW MCCOY MSN, RN, CNS-AG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 8TH AVE
FORT WORTH TX
76104-4110
US

IV. Provider business mailing address

PO BOX 1291
WEATHERFORD TX
76086-1291
US

V. Phone/Fax

Practice location:
  • Phone: 817-926-2544
  • Fax:
Mailing address:
  • Phone: 325-451-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberAP136405
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: