Provider Demographics
NPI:1801949276
Name:BOTTELSON, RANDALL ANDREW (BS)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:ANDREW
Last Name:BOTTELSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 98TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-4715
Mailing Address - Country:US
Mailing Address - Phone:952-881-2778
Mailing Address - Fax:952-881-2821
Practice Address - Street 1:601 W 98TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4715
Practice Address - Country:US
Practice Address - Phone:952-881-2778
Practice Address - Fax:952-881-2821
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management