Provider Demographics
NPI:1255009114
Name:HARRIS, JOHN BERNARD IV (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BERNARD
Last Name:HARRIS
Suffix:IV
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CIRCLE J DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-1980
Mailing Address - Country:US
Mailing Address - Phone:601-425-0092
Mailing Address - Fax:
Practice Address - Street 1:30 CIRCLE J DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1980
Practice Address - Country:US
Practice Address - Phone:601-425-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906168363LA2100X, 363LF0000X
TNAPN0000029981363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily