Basic Information
| Provider Information | |||||||||
| NPI: | 1003863432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMAN | ||||||||
| FirstName: | RANDAL | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GILMAN | ||||||||
| OtherFirstName: | RANDY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1288 KENDRA LN | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917849269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099313411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584475 | ||||||||
| FaxNumber: | 9095584143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 06/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14703 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA14703 | 05 | CA | MEDICAID | GR0058270 | 05 | CA | MEDICAID | GR0058271 | 05 | CA | MEDICAID |