Basic Information
| Provider Information | |||||||||
| NPI: | 1386688422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOELLER | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9621 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838502 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9398 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823200 | ||||||||
| FaxNumber: | 3607823244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD00044442 | WA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3745243 | 01 | AETNA | OTHER | P00212141 | 01 | RAILROAD MEDICARE | OTHER | 1153MO | 01 | REGENCE BLUE SHIELD | OTHER | 193291 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8421752 | 05 | WA | MEDICAID | AM9584005 | 01 | DEA | OTHER |