Healthcare Provider Details

I. General information

NPI: 1346871258
Provider Name (Legal Business Name): RANDALL HAGEMEISTER APRN-CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

4550 49TH AVE S APT 307
FARGO ND
58104-4555
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8000
  • Fax:
Mailing address:
  • Phone: 701-307-0524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR39311
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: