Basic Information
| Provider Information | |||||||||
| NPI: | 1811981921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERDET | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5410 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511025410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122522477 | ||||||||
| FaxNumber: | 7122525516 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 NEBRASKA ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511051436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122522477 | ||||||||
| FaxNumber: | 7122525516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1121 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 001427 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0092080 | 05 | IA | MEDICAID |