Provider Demographics
NPI:1336458959
Name:HARRIS, ALYSSA M (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:M
Other - Last Name:TRUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:SUITE A-540
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-258-6760
Mailing Address - Fax:859-258-6512
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE A-540
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-258-6760
Practice Address - Fax:859-258-6512
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1598363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100144660Medicaid
KYPA1598OtherSTATE LICENSURE
KYPA1598OtherSTATE LICENSURE