Healthcare Provider Details

I. General information

NPI: 1992081467
Provider Name (Legal Business Name): CODY BRYAN HARRIS CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 17TH ST
LEWISTON ID
83501-3652
US

IV. Provider business mailing address

PO BOX 341
LEWISTON ID
83501-0341
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-8416
  • Fax: 208-743-4642
Mailing address:
  • Phone: 208-743-8416
  • Fax: 208-743-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP000676
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1527A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: