Provider Demographics
NPI:1497278667
Name:RANDALL, ANDREW (DPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SANFORD BROADWAY MEDICAL BUILDING 736 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-4001
Mailing Address - Country:US
Mailing Address - Phone:701-234-6735
Mailing Address - Fax:
Practice Address - Street 1:SANFORD BROADWAY MEDICAL BUILDING 736 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-4001
Practice Address - Country:US
Practice Address - Phone:701-234-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11716225100000X
ND2226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist