Healthcare Provider Details

I. General information

NPI: 1518991702
Provider Name (Legal Business Name): JOHN WYATT HARRISON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 E THOMAS ROAD
PHOENIX AZ
85016-7711
US

IV. Provider business mailing address

PO BOX 26904
PHOENIX AZ
85068-6904
US

V. Phone/Fax

Practice location:
  • Phone: 480-596-8525
  • Fax: 480-596-8522
Mailing address:
  • Phone: 480-596-8525
  • Fax: 480-596-8522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number35565
License Number StateAZ

VIII. Authorized Official

Name: DR. JOHN WYATT HARRISON
Title or Position: DOCTOR
Credential: M.D.
Phone: 480-596-8525