Basic Information
| Provider Information | |||||||||
| NPI: | 1437408887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 W NC HIGHWAY 54 | ||||||||
| Address2: | STE 103 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277075572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
| FaxNumber: | 9197484441 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 NW 60TH ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523315100 | ||||||||
| FaxNumber: | 3523329607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 10/16/2017 | ||||||||
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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 | 163W00000X | RN9315572 | FL | N | Nursing Service Providers | Registered Nurse | 363LP0808X | ARNP9315572 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.