Provider Demographics
NPI:1144864398
Name:RANDALL, SALLIE ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:ELIZABETH
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-323-6047
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-5837
Practice Address - Country:US
Practice Address - Phone:859-323-6047
Practice Address - Fax:859-257-3873
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC088363AM0700X, 363A00000X, 363AS0400X
KYPA2895363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical