Provider Demographics
NPI:1558474197
Name:NELSON, RANDAL (PA)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 HIGHWAY 36 W
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3905
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:2355 HIGHWAY 36 W
Practice Address - Street 2:STE 100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3905
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970002312Medicaid
MN970002312Medicaid