Provider Demographics
NPI:1427378355
Name:MUTINY BAY MEDICAL PLLC
Entity Type:Organization
Organization Name:MUTINY BAY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-331-3391
Mailing Address - Street 1:5548 MYRTLE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-8776
Mailing Address - Country:US
Mailing Address - Phone:360-331-3391
Mailing Address - Fax:
Practice Address - Street 1:5548 MYRTLE AVE STE 201
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249-8776
Practice Address - Country:US
Practice Address - Phone:360-331-3391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty