Provider Demographics
NPI:1558039735
Name:HARRIES, TIMOTHY A
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:HARRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44661 STERLING HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7900
Mailing Address - Country:US
Mailing Address - Phone:907-420-0529
Mailing Address - Fax:907-420-0530
Practice Address - Street 1:44661 STERLING HWY STE A
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7900
Practice Address - Country:US
Practice Address - Phone:907-420-0529
Practice Address - Fax:907-420-0530
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17123593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1712359Medicaid