Provider Demographics
NPI:1871708321
Name:BOONE, RANDOLPH STEVEN (PA AND RRT)
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:STEVEN
Last Name:BOONE
Suffix:
Gender:M
Credentials:PA AND RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 W MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1946
Mailing Address - Country:US
Mailing Address - Phone:559-784-4944
Mailing Address - Fax:
Practice Address - Street 1:1119 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1946
Practice Address - Country:US
Practice Address - Phone:559-784-4944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARCP9514227900000X
CAPA12253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12253OtherPHYSICIAN ASSISTANT
CARCP9514OtherRCP