Provider Demographics
NPI:1285663658
Name:HARRISON, GAYLE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:ANN
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6440 SOUTH MILLROCK DRIVE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-863-1820
Practice Address - Fax:505-863-1898
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19928208000000X
CAA60050208000000X
WAMD00035594208000000X
SD7590208000000X
WY81831208000000X
NMMD20090692208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150718Medicaid
OR858597000OtherBLUE CROSS
OR9305053253002OtherEMPLOYER ID
OR134165Medicare ID - Type UnspecifiedMEDICARE-ZGBDR
ORG62443Medicare UPIN