Provider Demographics
NPI:1376154997
Name:HARRIS, MARY EMILY MORAN (PA)
Entity Type:Individual
Prefix:
First Name:MARY EMILY
Middle Name:MORAN
Last Name:HARRIS
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 1:1055 RIBAUT RD STE 30
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5447
Mailing Address - Country:US
Mailing Address - Phone:843-476-4702
Mailing Address - Fax:843-476-4290
Practice Address - Street 1:425 NORTH CEDAR ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6407
Practice Address - Country:US
Practice Address - Phone:843-476-4702
Practice Address - Fax:843-476-4290
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4195363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4956PAMedicaid