Provider Demographics
NPI:1598558801
Name:IPPOLITO, RANDALL MARK (CRNA)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:MARK
Last Name:IPPOLITO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:120 EMERALD VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584-0219
Mailing Address - Country:US
Mailing Address - Phone:580-301-1424
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered