Provider Demographics
NPI:1174871420
Name:RANDALL, MARY S (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:RANDALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-0000
Mailing Address - Fax:208-302-0055
Practice Address - Street 1:6140 W CURTISIAN AVE
Practice Address - Street 2:STE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8880
Practice Address - Country:US
Practice Address - Phone:208-302-0000
Practice Address - Fax:208-302-0055
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1157A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner