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General NPI Number Information
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NPI Number | 1760119622
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Entity Type | Individual
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Provider Name | TARA RANDOLPH PNP
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Gender | Female
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Dates
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Enumeration Date | 08/02/2022
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Last Update Date | 08/02/2022
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Provider Practice Location Address
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Address Line | 17705 HUTCHINS DR
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City | MINNETONKA
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State | MN
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Zip | 55345-4145
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Country | US
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Telephone | 952-401-8252
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Fax | 952-401-8286
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Provider Business Mailing Address
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Address Line | 6100 W 101ST ST
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City | BLOOMINGTON
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State | MN
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Zip | 55438-1816
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Country | US
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Telephone | 612-790-1297
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 9228
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License Number State | MN
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