Provider Demographics
NPI:1538350921
Name:NEWSOME-RANDALL, IRIS Y (FNP)
Entity type:Individual
Prefix:
First Name:IRIS
Middle Name:Y
Last Name:NEWSOME-RANDALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14380 MCGRAWS CORNER DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-1866
Mailing Address - Country:US
Mailing Address - Phone:703-753-3051
Mailing Address - Fax:
Practice Address - Street 1:14380 MCGRAWS CORNER DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-1866
Practice Address - Country:US
Practice Address - Phone:703-753-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2021-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167080363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017908M58Medicare PIN
VA017908M58Medicare UPIN