Provider Demographics
NPI:1568522779
Name:HARRIS, WAYNE DOUGLAS (CRNA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:DOUGLAS
Last Name:HARRIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:PO BOX 3127
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 HIGH ST
Practice Address - Street 2:WILLIAMSPORT HOSPITAL & MEDICAL CENTER
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3198
Practice Address - Country:US
Practice Address - Phone:570-321-2385
Practice Address - Fax:570-321-2479
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN503469L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018362650002Medicaid
PA103899OtherGEISINGER HEALTH PLAN
PA1018362650001Medicaid
PA1018362650003Medicaid
PA109085Medicare PIN