Basic Information
| Provider Information | |||||||||
| NPI: | 1912949124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDOLPH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 KIMBALL AVE | ||||||||
| Address2: | LL14 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192721590 | ||||||||
| FaxNumber: | 3192721535 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 2ND ST | ||||||||
| Address2: | |||||||||
| City: | GLADBROOK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414732707 | ||||||||
| FaxNumber: | 6414732641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 363A00000X | 000693 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.