Basic Information
Provider Information | |||||||||
NPI: | 1245889310 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RANDAZZO | ||||||||
FirstName: | VICTORIA | ||||||||
MiddleName: | PHAM | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD, AG-NP, RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7745 E WALNUT RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 928696515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7147439494 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13522 NEWPORT AVE STE 102 | ||||||||
Address2: |   | ||||||||
City: | TUSTIN | ||||||||
State: | CA | ||||||||
PostalCode: | 927803707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7145738200 | ||||||||
FaxNumber: | 7145739401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2019 | ||||||||
LastUpdateDate: | 09/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95012573 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP2300X | 95012573 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LG0600X | 95012573 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | 95012573 | 01 | CA | NURSE PRACTITIONER FURNISHING LICENSE | OTHER |