Provider Demographics
NPI:1124459797
Name:LAKE, RANDY LEN
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:LEN
Last Name:LAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13965 MOSSY STONE WAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-5024
Mailing Address - Country:US
Mailing Address - Phone:405-204-3389
Mailing Address - Fax:
Practice Address - Street 1:13965 MOSSY STONE WAY
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73025-5024
Practice Address - Country:US
Practice Address - Phone:405-204-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)