MEDICARE: SYDNEY ANNE RANDALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9120068	FL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1831875582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY ANNE RANDALL

Provider Business Mailing Address
First Line	:	4519 S 167TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-1356
Country	:	US
Telephone Number	:	612-578-2530
Fax Number	:

Provider Business Practice Location Address
First Line	:	4519 S 167TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-1356
Country	:	US
Telephone Number	:	612-578-2530
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2023
Last Update Date	:	02/04/2026

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Directions to “ SYDNEY ANNE RANDALL ” Practice Location

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