Provider Demographics
NPI:1255334066
Name:WRAALSTAD, RANDAL LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:LEE
Last Name:WRAALSTAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:714 N COLLEGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5812
Practice Address - Country:US
Practice Address - Phone:208-814-7150
Practice Address - Fax:208-814-7170
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP152213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804243900Medicaid
IDP00899555OtherMCRR
ID13508861Medicare PIN
IDU66389Medicare UPIN
IDP00899555OtherMCRR