Provider Demographics
NPI:1295957116
Name:HARDEN, RYAN MARK (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MARK
Last Name:HARDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LUNDORFF DR
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-5051
Mailing Address - Country:US
Mailing Address - Phone:320-245-2250
Mailing Address - Fax:320-245-2555
Practice Address - Street 1:204 LUNDORFF DR
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5051
Practice Address - Country:US
Practice Address - Phone:320-245-2250
Practice Address - Fax:320-245-2555
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00438361OtherRR MEDICARE PTAN
MN744153000Medicaid
MN35P56HAOtherBCBS
MN01-28054OtherMEDICA
P00438361OtherRR MEDICARE PTAN
MN080016125Medicare PIN