Provider Demographics
NPI:1477906733
Name:HARRISON, STEVEN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:HARRISON
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 1:5601 DOMINGO RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1610
Mailing Address - Country:US
Mailing Address - Phone:505-268-5295
Mailing Address - Fax:
Practice Address - Street 1:5601 DOMINGO RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1610
Practice Address - Country:US
Practice Address - Phone:505-268-5295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9311Medicaid