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General NPI Number Information
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NPI Number | 1306350640
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Entity Type | Individual
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Provider Name | NICHOLAS MARTIN HARRIS PTA
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Gender | Male
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Dates
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Enumeration Date | 11/22/2017
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Last Update Date | 10/24/2025
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Provider Practice Location Address
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Address Line | 7111 SOUTHCREST PKWY STE 105
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City | SOUTHAVEN
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State | MS
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Zip | 38671-4851
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Country | US
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Telephone | 901-261-2506
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Fax | 901-261-2590
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Provider Business Mailing Address
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Address Line | 4869 STONE CROSS DR
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-6989
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA5889
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License Number State | MS
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