Healthcare Provider Details

I. General information

NPI: 1093234411
Provider Name (Legal Business Name): MATTHEW HARRIS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40023 CROSS CREEK DR
HAMILTON MS
39746
US

IV. Provider business mailing address

40023 CROSS CREEK DR
HAMILTON MS
39746-8801
US

V. Phone/Fax

Practice location:
  • Phone: 662-343-5299
  • Fax: 662-343-8456
Mailing address:
  • Phone: 662-343-5299
  • Fax: 662-343-8456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902320
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: