Healthcare Provider Details

I. General information

NPI: 1457592396
Provider Name (Legal Business Name): RANDALL A BLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST BOX 356161, NE-306
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

14015 36TH AVE NE
SEATTLE WA
98125-3725
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-4022
  • Fax:
Mailing address:
  • Phone: 440-241-0706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD60671186
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: