Provider Demographics
NPI:1447642400
Name:PELLEW, RANDY MARLON (FNP)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:MARLON
Last Name:PELLEW
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27005 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1402
Mailing Address - Country:US
Mailing Address - Phone:718-470-7310
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-28
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily