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General NPI Number Information
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NPI Number | 1134344211
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Entity Type | Individual
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Provider Name | RANDALL C BENNETT P.A.
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Gender | Male
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 07/25/2007
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Provider Practice Location Address
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Address Line | 9570 REGENCY SQUARE BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32225-9103
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Country | US
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Telephone | 904-725-7100
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Fax | 904-720-0059
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Provider Business Mailing Address
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Address Line | 12079 BLACKFOOT TRL
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City | JACKSONVILLE
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State | FL
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Zip | 32223-3233
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Country | US
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Telephone | 904-292-9325
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2262
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License Number State | FL
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