Provider Demographics
NPI:1841277845
Name:HARRIS, KENNETH A (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S CHESTNUT STREET, SUITE A
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926
Mailing Address - Country:US
Mailing Address - Phone:509-962-7390
Mailing Address - Fax:509-925-6948
Practice Address - Street 1:611 S CHESTNUT STREET, SUITE A
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926
Practice Address - Country:US
Practice Address - Phone:509-962-7390
Practice Address - Fax:509-925-6948
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015916174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7079346Medicaid
WA1948603Medicaid
WA18531OtherL&I
WA7079346Medicaid
WA18531OtherL&I