1992250252 NPI number — RANDI MCKISSICK

Table of content: RANDI MCKISSICK (NPI 1992250252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992250252 NPI number — RANDI MCKISSICK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKISSICK
Provider First Name:
RANDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MASON
Provider Other First Name:
RANDI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BB(ASCP)
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992250252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5425 AUSTRALIAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89142-2702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-824-3611
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5425 AUSTRALIAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89142-2702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-824-3611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246QB0000X , with the licence number:  45151-TS-0 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 246QB0000X , with the licence number: 3137 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)