Healthcare Provider Details

I. General information

NPI: 1275641607
Provider Name (Legal Business Name): PETER DONALD HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 415 BOX 4345
APO AE
09114
DE

IV. Provider business mailing address

CMR 415 BOX 4345
APO AE
09114
DE

V. Phone/Fax

Practice location:
  • Phone: 4758582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB1396955
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: