Provider Demographics
NPI:1871670695
Name:HARRISON, KENNETH LEE JR (PA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:HARRISON
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3177 OCEAN VIEW BLVD
Mailing Address - Street 2:COMPREHENSIVE HEALTH CENTER/SAN YSIDRO HEALTH CENTER
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113
Mailing Address - Country:US
Mailing Address - Phone:619-231-9300
Mailing Address - Fax:619-858-1003
Practice Address - Street 1:3177 OCEAN VIEW BLVD.
Practice Address - Street 2:COMPREHENSIVE HEALTH CENTER/SAN YSIDRO HEALTH CENTER
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113
Practice Address - Country:US
Practice Address - Phone:619-231-9300
Practice Address - Fax:619-858-1003
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P67872Medicare UPIN
CAWPA12009AMedicare ID - Type Unspecified