Provider Demographics
NPI:1124412853
Name:HAAGENSON-BUCK, GARYT
Entity Type:Individual
Prefix:
First Name:GARYT
Middle Name:
Last Name:HAAGENSON-BUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11280 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BARRETT
Mailing Address - State:MN
Mailing Address - Zip Code:56311-1116
Mailing Address - Country:US
Mailing Address - Phone:218-731-0155
Mailing Address - Fax:
Practice Address - Street 1:11280 210TH ST
Practice Address - Street 2:
Practice Address - City:BARRETT
Practice Address - State:MN
Practice Address - Zip Code:56311-1116
Practice Address - Country:US
Practice Address - Phone:218-731-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer