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General NPI Number Information
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NPI Number | 1730283862
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Entity Type | Individual
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Provider Name | LESLIE ANGELETTE RANDOLPH-MOSS MPAS, PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/11/2006
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Last Update Date | 10/18/2023
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Provider Practice Location Address
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Address Line | 4600 MIDDLETON PARK CIR E APT D250
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City | JACKSONVILLE
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State | FL
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Zip | 32224-4684
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Country | US
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Telephone | 90-461-0339
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Fax |
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Provider Business Mailing Address
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Address Line | 116 CLARENDON RD
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City | ST JOHNS
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State | FL
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Zip | 32259-7079
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Country | US
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Telephone | 785-226-2115
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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 | 1061708
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9113425
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License Number State | FL
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