Provider Demographics
NPI:1841241676
Name:HARRIS, MARTHA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W LINCOLN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-222-3200
Mailing Address - Fax:618-222-3203
Practice Address - Street 1:311 W LINCOLN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-222-3200
Practice Address - Fax:618-222-3203
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO94978367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO915102420Medicaid
MO819330276Medicare PIN