Provider Demographics
NPI:1134563109
Name:HARRIS, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459001
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9101
Mailing Address - Country:US
Mailing Address - Phone:530-272-9780
Mailing Address - Fax:
Practice Address - Street 1:140 LITTON DR STE 100
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5078
Practice Address - Country:US
Practice Address - Phone:530-272-9780
Practice Address - Fax:530-272-0156
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1367352080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program