Provider Demographics
NPI:1093234411
Name:HARRIS, MATTHEW (FNP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40023 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MS
Mailing Address - Zip Code:39746-8801
Mailing Address - Country:US
Mailing Address - Phone:662-343-5299
Mailing Address - Fax:662-343-8456
Practice Address - Street 1:40023 CROSS CREEK DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MS
Practice Address - Zip Code:39746
Practice Address - Country:US
Practice Address - Phone:662-343-5299
Practice Address - Fax:662-343-8456
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902320363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS902320OtherFNP LICENSE