Healthcare Provider Details

I. General information

NPI: 1730148651
Provider Name (Legal Business Name): RANDALL I DYSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

2545 CHICAGO AVE SUITE 311
MINNEAPOLIS MN
55404-4522
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-7639
  • Fax: 612-872-0302
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 131417-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: