Provider Demographics
NPI:1487089504
Name:WIDTFELDT, RANDY (PA)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:WIDTFELDT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MONTVALE AVE
Mailing Address - Street 2:STE 1400
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3629
Mailing Address - Country:US
Mailing Address - Phone:781-279-7040
Mailing Address - Fax:781-279-8430
Practice Address - Street 1:92 MONTVALE AVE
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3647
Practice Address - Country:US
Practice Address - Phone:781-279-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4822363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical