Provider Demographics
NPI:1184617151
Name:HARRISON, JOHN CHARLES (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHARLES
Last Name:HARRISON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:9848 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5512
Practice Address - Country:US
Practice Address - Phone:704-323-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015XTMedicaid
NC2747158EMedicare ID - Type UnspecifiedINDIVIDUAL
NC89015XTMedicaid
NC0397730015Medicare NSC
NC0397730028Medicare NSC
2328654Medicare ID - Type UnspecifiedGROUP