Provider Demographics
NPI:1821360728
Name:HARRIS, DEREK R (MSN, APRN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MSN, APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4436
Mailing Address - Country:US
Mailing Address - Phone:318-828-2210
Mailing Address - Fax:318-828-2215
Practice Address - Street 1:1919 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4436
Practice Address - Country:US
Practice Address - Phone:318-828-2210
Practice Address - Fax:318-828-2215
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07181363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2330578Medicaid