Healthcare Provider Details

I. General information

NPI: 1124412853
Provider Name (Legal Business Name): GARYT HAAGENSON-BUCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11280 210TH ST
BARRETT MN
56311-1116
US

IV. Provider business mailing address

11280 210TH ST
BARRETT MN
56311-1116
US

V. Phone/Fax

Practice location:
  • Phone: 218-731-0155
  • Fax:
Mailing address:
  • Phone: 218-731-0155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: