Provider Demographics
NPI:1861573479
Name:STAGG, RANDOLPH LEE
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:LEE
Last Name:STAGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 W 78TH ST
Mailing Address - Street 2:SUITE 265
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8715
Mailing Address - Country:US
Mailing Address - Phone:952-934-6000
Mailing Address - Fax:952-934-6760
Practice Address - Street 1:80 W 78TH ST
Practice Address - Street 2:SUITE 265
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8715
Practice Address - Country:US
Practice Address - Phone:952-934-6000
Practice Address - Fax:952-934-6760
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNE595041887419332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies