Provider Demographics
NPI:1174148696
Name:RANDALL, COLTON JASON (PA-C)
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:JASON
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 BANKS LOWMAN RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-8102
Mailing Address - Country:US
Mailing Address - Phone:208-462-3533
Mailing Address - Fax:
Practice Address - Street 1:856 BANKS LOWMAN RD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83622-8102
Practice Address - Country:US
Practice Address - Phone:208-462-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant