Healthcare Provider Details

I. General information

NPI: 1891914370
Provider Name (Legal Business Name): HAROLD HERMAN RANDECKER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 90TH DR SE
LAKE STEVENS WA
98258-3791
US

IV. Provider business mailing address

1814 90TH DR SE
LAKE STEVENS WA
98258-3791
US

V. Phone/Fax

Practice location:
  • Phone: 425-829-0700
  • Fax: 253-216-3635
Mailing address:
  • Phone: 425-829-0700
  • Fax: 253-216-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14276
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number14276
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number14276
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number14276
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: