Provider Demographics
NPI: | 1033278866 |
---|---|
Name: | HARRIS, KAREN GAYE (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | KAREN |
Middle Name: | GAYE |
Last Name: | HARRIS |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | GAYE |
Other - Middle Name: | |
Other - Last Name: | HARRIS |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | DO |
Mailing Address - Street 1: | PO BOX 3158 |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97208-3158 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 200 S HAZEL DELL WAY |
Practice Address - Street 2: | |
Practice Address - City: | CANBY |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97013-7829 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-263-9500 |
Practice Address - Fax: | 503-263-1383 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-07 |
Last Update Date: | 2012-12-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 18948 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 069232 | Medicaid | |
OR | P00910531 | Other | RR MEDICARE |
OR | R152857 | Medicare PIN | |
OR | R152856 | Medicare PIN | |
OR | R152852 | Medicare PIN | |
OR | R152854 | Medicare PIN | |
OR | R152851 | Medicare PIN | |
OR | P00910531 | Other | RR MEDICARE |