Provider Demographics
NPI:1770374878
Name:HARRIS, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 LIBERTY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2291
Mailing Address - Country:US
Mailing Address - Phone:407-921-7450
Mailing Address - Fax:
Practice Address - Street 1:200 MISSISSIPPI ST # 30
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-4140
Practice Address - Country:US
Practice Address - Phone:662-538-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program