Provider Demographics
NPI:1376600668
Name:RUNDEL, MARK STANLEY (LMP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STANLEY
Last Name:RUNDEL
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6743 5TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-5014
Mailing Address - Country:US
Mailing Address - Phone:206-324-5744
Mailing Address - Fax:
Practice Address - Street 1:1605 12TH AVE
Practice Address - Street 2:SUITE 30
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2467
Practice Address - Country:US
Practice Address - Phone:206-324-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006014225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner