Basic Information
| Provider Information | |||||||||
| NPI: | 1295957116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDEN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 LUNDORFF DR | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 LUNDORFF DR | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49738 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00438361 | 01 | RR MEDICARE PTAN | OTHER | 744153000 | 05 | MN | MEDICAID | 35P56HA | 01 | MN | BCBS | OTHER | 01-28054 | 01 | MN | MEDICA | OTHER |