Basic Information
| Provider Information | |||||||||
| NPI: | 1780745679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2535 W. OAK STREET | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403821577 | ||||||||
| FaxNumber: | 9403875471 | ||||||||
| Practice Location | |||||||||
| Address1: | 2535 W. OAK STREET | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403821577 | ||||||||
| FaxNumber: | 9403875471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA04957 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00954314 | 01 | TX | RAILROAD MEDICARE | OTHER | P00453355 | 01 | TX | RAILROAD MEDICARE | OTHER | 714778 | 01 | TX | MEDICARE PART B | OTHER | 8Y1403 | 01 | TX | BC/BS TEXAS | OTHER | 1780745679 | 01 | TX | NPI | OTHER | 835N04 | 01 | TX | BCBS TX 02/01/2011 | OTHER | TXB120921 | 01 | TX | MEDICARE PART B - EFFECT 02/01/2011 | OTHER |