Provider Demographics
NPI:1730260019
Name:COUSINS, RANDOLPH P (PA)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:P
Last Name:COUSINS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 BLACKMON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-4478
Mailing Address - Country:US
Mailing Address - Phone:706-568-2700
Mailing Address - Fax:706-568-2705
Practice Address - Street 1:7301 BLACKMON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-4478
Practice Address - Country:US
Practice Address - Phone:706-568-2700
Practice Address - Fax:706-568-2705
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004428363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004428OtherLICENSE NUMBER