Provider Demographics
NPI:1376191858
Name:HARLESS, MATTHEW C
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:HARLESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JOHN MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25755-0002
Mailing Address - Country:US
Mailing Address - Phone:304-688-8101
Mailing Address - Fax:
Practice Address - Street 1:1 JOHN MARSHALL DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25755-0002
Practice Address - Country:US
Practice Address - Phone:304-688-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program