Provider Demographics
NPI:1386134369
Name:THORSON, RANDALL (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:THORSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21260 CHIPPENDALE AVE W
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-1427
Mailing Address - Country:US
Mailing Address - Phone:651-463-7181
Mailing Address - Fax:651-241-0829
Practice Address - Street 1:21260 CHIPPENDALE AVE W
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-1427
Practice Address - Country:US
Practice Address - Phone:651-463-7181
Practice Address - Fax:651-241-0829
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL15080207Q00000X
MN69892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDRL15080OtherND LICENSE