Provider Demographics
NPI:1548611049
Name:HARRIS, RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W COURT ST STE B
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4247
Mailing Address - Country:US
Mailing Address - Phone:870-236-6911
Mailing Address - Fax:
Practice Address - Street 1:630 W COURT ST STE B
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4247
Practice Address - Country:US
Practice Address - Phone:870-236-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-26
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-12415207Q00000X
FLTRN23601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE-12415OtherMEDICAL LICENSE