Healthcare Provider Details

I. General information

NPI: 1366278269
Provider Name (Legal Business Name): SAMUEL HARRIS DNP, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11008 DOUBLE EAGLE NE
ALBUQUERQUE NM
87111-6559
US

IV. Provider business mailing address

11008 DOUBLE EAGLE NE
ALBUQUERQUE NM
87111-6559
US

V. Phone/Fax

Practice location:
  • Phone: 505-440-5498
  • Fax:
Mailing address:
  • Phone: 505-440-5498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number90677
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: