Provider Demographics
NPI:1003428426
Name:HARRISON, SAMUEL GLEN II
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GLEN
Last Name:HARRISON
Suffix:II
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 1:1034 CICERONE RD
Mailing Address - Street 2:
Mailing Address - City:GANDEEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25243-8664
Mailing Address - Country:US
Mailing Address - Phone:304-577-9145
Mailing Address - Fax:
Practice Address - Street 1:1034 CICERONE RD
Practice Address - Street 2:
Practice Address - City:GANDEEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25243-8664
Practice Address - Country:US
Practice Address - Phone:304-577-9145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant