Healthcare Provider Details

I. General information

NPI: 1932469871
Provider Name (Legal Business Name): LAFE NELSON HARRIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4838 E BASELINE RD STE 122
MESA AZ
85206-4675
US

IV. Provider business mailing address

4838 E BASELINE RD STE 122
MESA AZ
85206-4675
US

V. Phone/Fax

Practice location:
  • Phone: 480-462-7015
  • Fax: 480-992-6798
Mailing address:
  • Phone: 480-462-7015
  • Fax: 480-992-6798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number9355610-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDOS-2354
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number006235
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: