Provider Demographics
NPI:1487684049
Name:HARRIS, GREG EUGENE (PA-C)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:EUGENE
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 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:1840 N JASPER DR STE 2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1634
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3387363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP81359Medicare UPIN
108133Medicare ID - Type Unspecified