Provider Demographics
NPI:1275847394
Name:HARRIS, MICHAEL SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:3330 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3841
Practice Address - Country:US
Practice Address - Phone:318-449-2415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2353454Medicaid
LA2353454Medicaid