Provider Demographics
NPI:1013432434
Name:HARMON, MATTHEW DUANE (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DUANE
Last Name:HARMON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 NATCHEZ TRACE AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7947
Mailing Address - Country:US
Mailing Address - Phone:270-393-1912
Mailing Address - Fax:270-393-1913
Practice Address - Street 1:250 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1760
Practice Address - Country:US
Practice Address - Phone:270-393-1912
Practice Address - Fax:270-393-1913
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY3011691367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1132791OtherRN LICENSE
KY3011691OtherAPRN