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1760119622 NPI number — TARA RANDOLPH PNP

NPI Number: 1760119622
Health Care Provider/Practitioner: TARA RANDOLPH PNP

Information about “1760119622” NPI (TARA RANDOLPH PNP) exists in 1760119622 in HTML format HTML  |  1760119622 in plain Text format TXT  |  1760119622 in PDF (Portable Document Format) PDF  |  1760119622 in an XML format XML  formats.

NPI Number : 1760119622 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1760119622",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "RANDOLPH",
    "FirstName": "TARA",
    "MiddleName": null,
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "PNP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "KLUXDAL",
    "OtherFirstName": "TARA",
    "OtherMiddleName": null,
    "OtherNamePrefix": "MRS.",
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "6100 W 101ST ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BLOOMINGTON",
    "MailingAddressStateName": "MN",
    "MailingAddressPostalCode": "55438-1816",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "612-790-1297",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "17705 HUTCHINS DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "MINNETONKA",
    "PracticeLocationAddressStateName": "MN",
    "PracticeLocationAddressPostalCode": "55345-4145",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "952-401-8252",
    "PracticeLocationAddressFaxNumber": "952-401-8286",
    "EnumerationDate": "08/02/2022",
    "LastUpdateDate": "08/02/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "363LP0200X",
        "TaxonomyName": "Pediatric Nurse Practitioner",
        "LicenseNumber": "9228",
        "LicenseNumberStateCode": "MN",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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