Provider Demographics
NPI:1730133489
Name:HARRISON, JOHN WYATT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WYATT
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8144 E CACTUS RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-5266
Mailing Address - Country:US
Mailing Address - Phone:480-596-8525
Mailing Address - Fax:480-596-8522
Practice Address - Street 1:8144 E CACTUS RD
Practice Address - Street 2:SUITE 800
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5266
Practice Address - Country:US
Practice Address - Phone:480-596-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43224207L00000X
AZ35565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0445150OtherBC/BS
AZ115520Medicaid
AZH62221Medicare UPIN
AZ115520Medicaid