Healthcare Provider Details

I. General information

NPI: 1730174343
Provider Name (Legal Business Name): RANDALL JAMES NETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR 90 MDG
FE WARREN AFB WY
82005-3906
US

IV. Provider business mailing address

6900 ALDEN DR 90 MDG FLIGHT MEDICINE CLINIC SGO AF
FE WARREN AFB WY
82005-3906
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-3461
  • Fax: 307-773-3809
Mailing address:
  • Phone: 307-773-3461
  • Fax: 307-773-3809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01056810A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: