Provider Demographics
NPI:1730174343
Name:NETT, RANDALL JAMES (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAMES
Last Name:NETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 ALDEN DR
Mailing Address - Street 2:90 MDG FLIGHT MEDICINE CLINIC SGO AF
Mailing Address - City:FE WARREN AFB
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-3461
Mailing Address - Fax:307-773-3809
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:90 MDG
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-3461
Practice Address - Fax:307-773-3809
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056810A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN