Provider Demographics
NPI:1659737419
Name:HARRIS, WILSON ANDREW III (MS, RDN, LDN)
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:ANDREW
Last Name:HARRIS
Suffix:III
Gender:M
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 JABARA AVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON A F B
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-0407
Mailing Address - Fax:
Practice Address - Street 1:1050 JABARA AVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON A F B
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-0407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1992133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered