Provider Demographics
NPI:1083864334
Name:HARRIS, GREGORY MARK
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MARK
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
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 480
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:VA
Mailing Address - Zip Code:20116-0480
Mailing Address - Country:US
Mailing Address - Phone:703-887-0072
Mailing Address - Fax:540-428-3724
Practice Address - Street 1:6248 GHADBAN CT
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20187-7945
Practice Address - Country:US
Practice Address - Phone:703-887-0072
Practice Address - Fax:540-428-3724
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705 012901171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications