Provider Demographics
NPI:1033307996
Name:HARRIMAN, AMBER L (PA)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:L
Last Name:HARRIMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278
Mailing Address - Country:US
Mailing Address - Phone:618-282-3831
Mailing Address - Fax:618-282-5476
Practice Address - Street 1:325 SPRING STREET
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278
Practice Address - Country:US
Practice Address - Phone:618-282-3831
Practice Address - Fax:618-282-5476
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2868052Medicare PIN