Provider Demographics
NPI:1982751830
Name:HARRIS, SANDRA MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972
Mailing Address - Country:US
Mailing Address - Phone:518-643-7037
Mailing Address - Fax:518-643-2125
Practice Address - Street 1:9 ELM STREET
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972
Practice Address - Country:US
Practice Address - Phone:518-643-7037
Practice Address - Fax:518-643-2125
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332292363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP15231Medicare UPIN