Provider Demographics
NPI:1669806485
Name:HARRIS, GABRIEL M (PT, DPT)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:M
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2758
Mailing Address - Country:US
Mailing Address - Phone:479-968-2525
Mailing Address - Fax:479-968-2538
Practice Address - Street 1:2100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2758
Practice Address - Country:US
Practice Address - Phone:479-968-2525
Practice Address - Fax:479-968-2538
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200789721Medicaid
ARA002OtherTRICARE
AR318924YVJ8Medicare PIN