Provider Demographics
NPI:1275661621
Name:HARRIS, JOHN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5914
Mailing Address - Country:US
Mailing Address - Phone:318-232-7700
Mailing Address - Fax:318-232-7148
Practice Address - Street 1:1118 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5914
Practice Address - Country:US
Practice Address - Phone:318-232-7700
Practice Address - Fax:318-232-7148
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA71637367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA71637OtherLICENSE
LA5X155C607Medicare ID - Type Unspecified