Provider Demographics
NPI:1396038170
Name:HARRISON, MICHAEL (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HARRISON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8855 NE 150TH ST
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:OK
Mailing Address - Zip Code:73541-2542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HWY 264 MILEPOST 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-4000
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704196884163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid