Provider Demographics
NPI:1407993553
Name:NOTEBLOOM, RANDY A (PT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:A
Last Name:NOTEBLOOM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLIVE WAY MSC M4-PA
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:904 7TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1132
Practice Address - Country:US
Practice Address - Phone:206-223-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000032912251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANO5497OtherBLUE SHIELD #
WAUS1051973OtherAETNA SPECIALIST PIN
WA0039585OtherLABOR AND INDUSTRIES #
WA8342677Medicaid
WAP00079877OtherRAILROAD MEDICARE
WA0039585OtherLABOR AND INDUSTRIES #
WA8802734Medicare PIN