Provider Demographics
NPI:1689206534
Name:HARRIS, CHARLIE
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:HARRIS
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 1:11502 MEADOW LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5917
Mailing Address - Country:US
Mailing Address - Phone:763-249-5287
Mailing Address - Fax:
Practice Address - Street 1:1450 ALTA VISTA ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-4327
Practice Address - Country:US
Practice Address - Phone:763-249-5287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program