Provider Demographics
NPI:1730283862
Name:RANDOLPH-MOSS, LESLIE ANGELETTE (MPAS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANGELETTE
Last Name:RANDOLPH-MOSS
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CLARENDON RD
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7079
Mailing Address - Country:US
Mailing Address - Phone:785-226-2115
Mailing Address - Fax:
Practice Address - Street 1:4600 MIDDLETON PARK CIR E APT D250
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-4684
Practice Address - Country:US
Practice Address - Phone:090-461-0339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1061708363A00000X
FLPA9113425363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant