Provider Demographics
NPI:1760119622
Name:RANDOLPH, TARA (PNP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:KLUXDAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6100 W 101ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1816
Mailing Address - Country:US
Mailing Address - Phone:612-790-1297
Mailing Address - Fax:
Practice Address - Street 1:17705 HUTCHINS DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4145
Practice Address - Country:US
Practice Address - Phone:952-401-8252
Practice Address - Fax:952-401-8286
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9228363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics