Healthcare Provider Details

I. General information

NPI: 1407993553
Provider Name (Legal Business Name): RANDY A NOTEBLOOM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 7TH AVE
SEATTLE WA
98104-1132
US

IV. Provider business mailing address

1100 OLIVE WAY MSC M4-PA
SEATTLE WA
98101-1873
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-6487
  • Fax:
Mailing address:
  • Phone: 206-515-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT00003291
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: