Provider Demographics
NPI:1023542255
Name:HARSTAD, MARK ROY (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROY
Last Name:HARSTAD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SPRUCE AVE NE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2517
Mailing Address - Country:US
Mailing Address - Phone:763-333-6075
Mailing Address - Fax:
Practice Address - Street 1:206 SPRUCE AVE NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2517
Practice Address - Country:US
Practice Address - Phone:763-333-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR201897-7163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine