Healthcare Provider Details

I. General information

NPI: 1427670520
Provider Name (Legal Business Name): MATTHEW ALAN RAND PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 FAIRMOUNT AVE
PORT ANGELES WA
98363-9514
US

IV. Provider business mailing address

1793 13TH ST SE
SALEM OR
97302-2541
US

V. Phone/Fax

Practice location:
  • Phone: 360-457-0760
  • Fax: 360-994-4975
Mailing address:
  • Phone: 503-362-8385
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5039-23
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61323159
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: