Provider Demographics
NPI:1942341086
Name:RANDALL, NATHAN RICHARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:RICHARD
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-0160
Mailing Address - Country:US
Mailing Address - Phone:701-477-6111
Mailing Address - Fax:701-477-8410
Practice Address - Street 1:1 MAIN HOSPITAL ROAD
Practice Address - Street 2:BOX 160
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-0160
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:701-477-8410
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4095213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00E40950Medicare PIN