Basic Information
Provider Information | |||||||||
NPI: | 1023098142 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLEBY | ||||||||
FirstName: | RANDY | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1843 | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933031843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146373530 | ||||||||
FaxNumber: | 9145602227 | ||||||||
Practice Location | |||||||||
Address1: | 1700 MOUNT VERNON AVE | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933064018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6613262128 | ||||||||
FaxNumber: | 6613262129 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 10/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 326 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163W00000X | 246857 | CA | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | RN2468570 | 05 | CA |   | MEDICAID |