Basic Information
| Provider Information | |||||||||
| NPI: | 1538135504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | WARREN | ||||||||
| OtherFirstName: | RANDALL | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11475 ROBINSON DR NW | ||||||||
| Address2: | 21110Q | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554333746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635879000 | ||||||||
| FaxNumber: | 7635879130 | ||||||||
| Practice Location | |||||||||
| Address1: | 11475 ROBINSON DR NW | ||||||||
| Address2: | 21110Q | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554333746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635879000 | ||||||||
| FaxNumber: | 7635879130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25916 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 958502800 | 05 | MN | MEDICAID |