Provider Demographics
NPI:1093457079
Name:SANDERS, HARLEY DAVID (PRSS)
Entity Type:Individual
Prefix:MR
First Name:HARLEY
Middle Name:DAVID
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-1437
Mailing Address - Country:US
Mailing Address - Phone:304-205-3004
Mailing Address - Fax:
Practice Address - Street 1:1053 2ND AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-1437
Practice Address - Country:US
Practice Address - Phone:304-205-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist