=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336142009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL A OW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 MEDICAL PLAZA DR STE 225 & 235
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-1391
-----------------------------------------------------
Fax | 916-782-5992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 EXPOSITION BLVD BLDG 700
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95815-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-736-3408
-----------------------------------------------------
Fax | 916-233-4171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | G86601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------