Provider Demographics
NPI:1417086299
Name:MOON, RANDALL JOSEPH (RN)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JOSEPH
Last Name:MOON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 WALNUT TREE LN
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-6979
Mailing Address - Country:US
Mailing Address - Phone:530-892-2641
Mailing Address - Fax:
Practice Address - Street 1:1531 ESPLANADE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-332-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA384655163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant