Provider Demographics
NPI:1073104238
Name:HARRIS, MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:PANORA
Mailing Address - State:IA
Mailing Address - Zip Code:50216
Mailing Address - Country:US
Mailing Address - Phone:641-431-1038
Mailing Address - Fax:
Practice Address - Street 1:6314 WILSON DR
Practice Address - Street 2:
Practice Address - City:PANORA
Practice Address - State:IA
Practice Address - Zip Code:50216
Practice Address - Country:US
Practice Address - Phone:641-431-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA100899225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant