Provider Demographics
NPI:1164954020
Name:RANDALL, BRIANNA KAY (PAC)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:KAY
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:KAY
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3366 OAKDALE AVE N
Mailing Address - Street 2:STE 104
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2948
Mailing Address - Country:US
Mailing Address - Phone:763-520-7870
Mailing Address - Fax:763-520-7580
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:STE 104
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-520-7870
Practice Address - Fax:763-520-7580
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164954020Medicaid