Provider Demographics
NPI:1295366029
Name:SAMPSON, RANDALL JAY
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAY
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24668 HAMLET AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8781
Mailing Address - Country:US
Mailing Address - Phone:612-290-9056
Mailing Address - Fax:651-464-5671
Practice Address - Street 1:24668 HAMLET AVE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-8781
Practice Address - Country:US
Practice Address - Phone:612-290-9056
Practice Address - Fax:651-464-5671
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC743839171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor