Healthcare Provider Details

I. General information

NPI: 1124064258
Provider Name (Legal Business Name): RANDALL WAYNE YOUNG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 JUDSON RD
LONGVIEW TX
75601-5113
US

IV. Provider business mailing address

P.O. BOX 2527
LONGVIEW TX
75606-2527
US

V. Phone/Fax

Practice location:
  • Phone: 903-331-0506
  • Fax: 903-331-0462
Mailing address:
  • Phone: 903-331-0506
  • Fax: 903-331-0462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number72566
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number660218
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: