Basic Information
| Provider Information | |||||||||
| NPI: | 1588612063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEA | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034425630 | ||||||||
| FaxNumber: | 6034425631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | LA015413 | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3095403 | 05 | NH | MEDICAID | 1021450 | 05 | VT | MEDICAID | 1346420 | 05 | LA | MEDICAID |