Provider Demographics
NPI:1477727543
Name:HARRIS, TYRA CARTHENA (MD)
Entity Type:Individual
Prefix:DR
First Name:TYRA
Middle Name:CARTHENA
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3886 PRINCETON LAKES WAY SW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5511
Mailing Address - Country:US
Mailing Address - Phone:404-389-1234
Mailing Address - Fax:404-389-1114
Practice Address - Street 1:3886 PRINCETON LAKES WAY SW
Practice Address - Street 2:SUITE 120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5511
Practice Address - Country:US
Practice Address - Phone:404-389-1234
Practice Address - Fax:404-389-1114
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104262AMedicaid