Provider Demographics
NPI:1851332316
Name:HARRIS, TINA M (PT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 N FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:KS
Mailing Address - Zip Code:67701-2322
Mailing Address - Country:US
Mailing Address - Phone:785-462-8008
Mailing Address - Fax:785-460-8080
Practice Address - Street 1:270 N FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:KS
Practice Address - Zip Code:67701-2322
Practice Address - Country:US
Practice Address - Phone:785-462-8008
Practice Address - Fax:785-460-8080
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-2054174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
059714OtherBLUE CROSS BLUE SHIELD
650005073OtherRAILROAD MEDICARE
KS100319310AMedicaid
KS100319310AMedicaid