Healthcare Provider Details

I. General information

NPI: 1043283336
Provider Name (Legal Business Name): RANDY J KJORSTAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 NW 4TH ST STE A
REDMOND OR
97756-1328
US

IV. Provider business mailing address

PO BOX 428
JACKSON WY
83001-0428
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-7761
  • Fax: 541-598-3485
Mailing address:
  • Phone: 307-739-7690
  • Fax: 307-739-7644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-9325
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12855
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9756A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: