Provider Demographics
NPI:1073517793
Name:GRIFFITH, RANDALL GRAY (ARNP)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:GRAY
Last Name:GRIFFITH
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 5TH ST SE STE 1500
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4603
Mailing Address - Country:US
Mailing Address - Phone:888-280-5513
Mailing Address - Fax:
Practice Address - Street 1:1450 5TH ST SE STE 1500
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4603
Practice Address - Country:US
Practice Address - Phone:888-280-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005740363LF0000X
WAAP3005740363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS80905Medicare UPIN
WA1549ROOtherREGENCE RIDER #
WA0145248OtherLABOR AND INDUSTRIES
WAAB19140Medicare ID - Type UnspecifiedPART B
WA9630286OtherDSHS