Healthcare Provider Details

I. General information

NPI: 1962436782
Provider Name (Legal Business Name): AMY HARRISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 E FLORIDA AVE STE 104
HEMET CA
92544-4711
US

IV. Provider business mailing address

41889 E. FLORIDA AVE.
HEMET CA
92544
US

V. Phone/Fax

Practice location:
  • Phone: 951-414-4011
  • Fax:
Mailing address:
  • Phone: 951-652-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-103486
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG175785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: