MEDICARE: WANDA HARRIS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA002318	GA

General Provider Information

NPI Number	:	1235347196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA HARRIS PTA

Provider Business Mailing Address
First Line	:	3737 NINA CT
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-5701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 ATHENS HWY
Second Line	:	SUITE 600
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-2277
Country	:	US
Telephone Number	:	770-554-2307
Fax Number	:	770-554-2309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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