Provider Demographics
NPI:1922066455
Name:HARRIS, STEVEN WAYNE (PA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:WAYNE
Last Name:HARRIS
Suffix:
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 1:1620 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1008
Mailing Address - Country:US
Mailing Address - Phone:801-822-2234
Mailing Address - Fax:
Practice Address - Street 1:3917 WEST ROAD #250
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-5302
Practice Address - Country:US
Practice Address - Phone:505-661-4147
Practice Address - Fax:505-661-4199
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53426961206363A00000X
NMPA2011-0036363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870281028000Medicaid
UTP00084336OtherPALMETTO GBA
UTP93629Medicare UPIN
UT005502544Medicare ID - Type UnspecifiedMEDICARE