Healthcare Provider Details

I. General information

NPI: 1003548637
Provider Name (Legal Business Name): J'WOIN MAALIK HARRISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100254
GAINESVILLE FL
32610-0254
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-7906
  • Fax:
Mailing address:
  • Phone: 352-273-6438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11021888
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberAPRN11021888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: