Provider Demographics
NPI:1366512691
Name:NAKASONE, RANDY MASAO (PT)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:MASAO
Last Name:NAKASONE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4349
Mailing Address - Country:US
Mailing Address - Phone:505-425-7762
Mailing Address - Fax:505-454-9880
Practice Address - Street 1:508 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4349
Practice Address - Country:US
Practice Address - Phone:505-425-7762
Practice Address - Fax:505-454-9880
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1308OtherPT LICENSE