Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | PT00003291 | WA |
NPI | 1407993553 |
---|---|
Provider Name | Randy A Notebloom |
First Address | Seattle, WA 98101-1873 |
Second Address | Seattle, WA 98104-1132 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 09/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0039585 | LABOR AND INDUSTRIES # (01) | WA |
8342677 | (05) | WA |
NO5497 | BLUE SHIELD # (01) | WA |
P00079877 | RAILROAD MEDICARE (01) | WA |
Q12287 | (02) | |
US1051973 | AETNA SPECIALIST PIN (01) | WA |