Provider Demographics
NPI:1851559652
Name:GILLEN, RANDAL D (LMP)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:D
Last Name:GILLEN
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 1:314 1/2 N PINE ST
Mailing Address - Street 2:#2
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3373
Mailing Address - Country:US
Mailing Address - Phone:509-929-1162
Mailing Address - Fax:
Practice Address - Street 1:507 N PINE ST
Practice Address - Street 2:SUITE E
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-5024
Practice Address - Country:US
Practice Address - Phone:509-925-1525
Practice Address - Fax:509-925-1526
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist