Provider Demographics
NPI:1255665915
Name:HARRISON, JANELLE (PA)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25505 149TH RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2814
Mailing Address - Country:US
Mailing Address - Phone:678-733-0926
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP73130363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical