Provider Demographics
NPI:1528196169
Name:LOCKE-HARRIS, ELETHEA GEORGE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELETHEA
Middle Name:GEORGE
Last Name:LOCKE-HARRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELETHEA
Other - Middle Name:GEORGE
Other - Last Name:HARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:161 FORT WASHINGTON AVE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3729
Mailing Address - Country:US
Mailing Address - Phone:212-305-4076
Mailing Address - Fax:212-305-8560
Practice Address - Street 1:2251 N HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2601
Practice Address - Country:US
Practice Address - Phone:714-449-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011229-1363A00000X
CA22263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant