Basic Information
| Provider Information | |||||||||
| NPI: | 1295838605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHADWELL | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 CANYON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864428624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284441491 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 CANYON RD BLDG B | ||||||||
| Address2: | |||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864428624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284441491 | ||||||||
| FaxNumber: | 4357871913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 105209-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000012642 | 05 | UT | MEDICAID |