Provider Demographics
NPI:1043208960
Name:TWENHAFEL, RANDALL (PNP)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:TWENHAFEL
Suffix:
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E BOGARD RD STE 233
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7185
Mailing Address - Country:US
Mailing Address - Phone:907-357-4543
Mailing Address - Fax:
Practice Address - Street 1:950 E BOGARD RD STE 233
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7185
Practice Address - Country:US
Practice Address - Phone:907-357-4543
Practice Address - Fax:907-357-4533
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1145363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0141Medicaid