MEDICARE: MARK ROY HARSTAD RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	R201897-7	MN

General Provider Information

NPI Number	:	1023542255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ROY HARSTAD RN

Provider Business Mailing Address
First Line	:	206 SPRUCE AVE NE
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-2517
Country	:	US
Telephone Number	:	763-333-6075
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 SPRUCE AVE NE
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-2517
Country	:	US
Telephone Number	:	763-333-6075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2017
Last Update Date	:	04/13/2017

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