Provider Demographics
NPI:1043462062
Name:HARRIS, SHIRLEY (LPTA)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4760
Mailing Address - Country:US
Mailing Address - Phone:907-374-0884
Mailing Address - Fax:
Practice Address - Street 1:324 SKYRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-1205
Practice Address - Country:US
Practice Address - Phone:907-479-4911
Practice Address - Fax:907-374-4934
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK760225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant