Provider Demographics
NPI:1205925120
Name:LANUM, BRUCE RANDALL (RN, MN, CS, FNP)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:RANDALL
Last Name:LANUM
Suffix:
Gender:M
Credentials:RN, MN, CS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4401 BRIDGEPORT WAY W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4201
Mailing Address - Country:US
Mailing Address - Phone:253-564-4157
Mailing Address - Fax:253-564-4813
Practice Address - Street 1:4401 BRIDGEPORT WAY W
Practice Address - Street 2:ATTN CREDENTIALING
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4201
Practice Address - Country:US
Practice Address - Phone:253-564-4157
Practice Address - Fax:253-564-4813
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60060142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN