Healthcare Provider Details

I. General information

NPI: 1255945556
Provider Name (Legal Business Name): DEREK J HARDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 WIECKING CTR
MANKATO MN
56001-6062
US

IV. Provider business mailing address

53465 410TH ST
BINGHAM LAKE MN
56118-2063
US

V. Phone/Fax

Practice location:
  • Phone: 507-389-1899
  • Fax:
Mailing address:
  • Phone: 507-221-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: