MEDICARE: MR. RANDAL CARL CLAUSSEN RN

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	163W00000X	Registered Nurse	60865811	WA
2	363LF0000X	Family Nurse Practitioner	AP61216137	WA

General Provider Information

NPI Number	:	1578105458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDAL CARL CLAUSSEN RN

Provider Business Mailing Address
First Line	:	2015 S EDMUNDS ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98108-1928
Country	:	US
Telephone Number	:	253-278-6906
Fax Number	:

Provider Business Practice Location Address
First Line	:	2015 S EDMUNDS ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98108-1928
Country	:	US
Telephone Number	:	253-278-6906
Fax Number	:

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

Provider Enumeration Date	:	10/12/2019
Last Update Date	:	10/04/2021

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