Provider Demographics
NPI:1013029735
Name:WILEY, RANDALL E (DC, MSN, ARNP)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:E
Last Name:WILEY
Suffix:
Gender:M
Credentials:DC, MSN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0070
Mailing Address - Country:US
Mailing Address - Phone:509-634-2900
Mailing Address - Fax:
Practice Address - Street 1:617 BENTON ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9636
Practice Address - Country:US
Practice Address - Phone:509-422-7416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556249111N00000X
WAN361159228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0104556249OtherVA STATE LICENSE
G02442C01Medicare PIN