Provider Demographics
NPI:1730112889
Name:HARRIS, GAYLE RYAN (PA)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:RYAN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7316 WALLACE RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6034
Mailing Address - Country:US
Mailing Address - Phone:704-776-0489
Mailing Address - Fax:
Practice Address - Street 1:7316 WALLACE RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-6034
Practice Address - Country:US
Practice Address - Phone:704-776-0489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101865363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102233Medicaid
NCR86553Medicare UPIN
NC2753086AMedicare ID - Type Unspecified