MEDICARE: RANDALL TWENHAFEL PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	1145	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043208960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL TWENHAFEL PNP

Provider Business Mailing Address
First Line	:	950 E BOGARD RD STE 233
Second Line	:
City	:	WASILLA
State	:	AK
Zip	:	99654-7185
Country	:	US
Telephone Number	:	907-357-4543
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 E BOGARD RD STE 233
Second Line	:
City	:	WASILLA
State	:	AK
Zip	:	99654-7185
Country	:	US
Telephone Number	:	907-357-4543
Fax Number	:	907-357-4533

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	12/14/2011

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