Provider Demographics
NPI:1518991702
Name:JOHN WYATT HARRISON MD PC
Entity Type:Organization
Organization Name:JOHN WYATT HARRISON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WYATT
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-596-8525
Mailing Address - Street 1:PO BOX 26904
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-6904
Mailing Address - Country:US
Mailing Address - Phone:480-596-8525
Mailing Address - Fax:480-596-8522
Practice Address - Street 1:1930 E THOMAS ROAD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7711
Practice Address - Country:US
Practice Address - Phone:480-596-8525
Practice Address - Fax:480-596-8522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00343000OtherRAILROAD MEDICARE
AZ0445150OtherBLUE CROSS BLUE SHIELD
AZZB0974OtherHEALTHNET
AZ115520Medicaid
AZ115520Medicaid
AZZ110645Medicare PIN