Normocalcemic primary hyperparathyroidism (nPHPT) is a variant of classic hypercalcemic primary hyperparathyroidism characterized by normal serum and ionized calcium with elevated parathyroid hormone levels. Accurate diagnosis of nPHPT, which can only be confirmed after all potential causes of secondary hyperparathyroidism have been ruled out, is central to management decisions. There is a wide range of clinical presentations for patients with nPHPT, which is often diagnosed in selected populations undergoing evaluation for osteoporosis or kidney stone disease. Management options for nPHPT include parathyroidectomy versus observation for the development of end-organ damage, with or without pharmacologic therapy for related conditions. There are unique considerations for the preoperative evaluation and operative management of nPHPT, given patients are more likely to have multi-gland parathyroid disease and negative localizing imaging. Small studies demonstrating improvements in bone mineral density for patients with nPHPT treated with parathyroidectomy provide support for operative management in the setting of osteoporosis. Given inadequate data on the natural history of nPHPT and the outcomes of operative management, we recommend shared decision-making with patients, taking into account the certainty of the diagnosis, the likelihood of benefiting from parathyroidectomy, and the risks of surgery.