Provider Demographics
NPI:1053862300
Name:HARRIMAN, NATHANIEL SPENCER (MSS, PA-C)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:SPENCER
Last Name:HARRIMAN
Suffix:
Gender:M
Credentials:MSS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1669
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349
Mailing Address - Country:US
Mailing Address - Phone:928-722-6112
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1896 E BABBITT LN
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-722-6112
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6552363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ190373Medicaid