Provider Demographics
NPI:1396191763
Name:HARRIS, KENAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KENAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-4356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 W SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-4844
Practice Address - Country:US
Practice Address - Phone:702-916-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1741363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1093772204Medicaid