Healthcare Provider Details

I. General information

NPI: 1811995889
Provider Name (Legal Business Name): DENNIS HARKNESS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 WATERMAN WAY
TAVARES FL
32778-5252
US

IV. Provider business mailing address

3120 WATERMAN WAY
TAVARES FL
32778-5252
US

V. Phone/Fax

Practice location:
  • Phone: 352-343-1216
  • Fax: 352-343-1582
Mailing address:
  • Phone: 352-343-1216
  • Fax: 352-343-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103327
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: