Healthcare Provider Details

I. General information

NPI: 1982967451
Provider Name (Legal Business Name): DUSTIN CHARLES RANDALL CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 S. WALNUT STREET
FREEMAN SD
57029
US

IV. Provider business mailing address

804 S WALNUT ST
FREEMAN SD
57029-2033
US

V. Phone/Fax

Practice location:
  • Phone: 605-925-4219
  • Fax: 605-925-4220
Mailing address:
  • Phone: 605-925-4219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000712
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: