Provider Demographics
NPI:1255648598
Name:HARRIS, MATTHEW EMMETT (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EMMETT
Last Name:HARRIS
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 1:1625 FOXTRAIL DR STE 190
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9089
Mailing Address - Country:US
Mailing Address - Phone:970-619-6900
Mailing Address - Fax:
Practice Address - Street 1:1625 FOXTRAIL DR STE 190
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9089
Practice Address - Country:US
Practice Address - Phone:970-619-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3030OtherSTATE LICENSE
CO33388270Medicaid
CO017155OtherKAISER COMMERCIAL NUMBER
CO3030OtherSTATE LICENSE