Healthcare Provider Details

I. General information

NPI: 1598264731
Provider Name (Legal Business Name): RAUSTIN W HARRIS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 05/24/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-2154
  • Fax:
Mailing address:
  • Phone: 210-916-2154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1300977
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: