Healthcare Provider Details

I. General information

NPI: 1386386316
Provider Name (Legal Business Name): MEGHAN SPROUSE RANDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 BROWNS WAY RD
MIDLOTHIAN VA
23114-9501
US

IV. Provider business mailing address

2827 PRESTON PARK WAY
SANDY HOOK VA
23153
US

V. Phone/Fax

Practice location:
  • Phone: 804-419-9101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008844
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: