Provider Demographics
NPI:1215182100
Name:RATHBURN, RANDALL ANTHONY
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:ANTHONY
Last Name:RATHBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 NE 141ST WAY
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-3021
Mailing Address - Country:US
Mailing Address - Phone:503-929-0649
Mailing Address - Fax:
Practice Address - Street 1:2202 NE 141ST WAY
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-3021
Practice Address - Country:US
Practice Address - Phone:503-929-0649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602878295332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies