Provider Demographics
NPI:1124165972
Name:HARRISON, WANDA V (MD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:V
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 HARRODSBURG RD
Mailing Address - Street 2:SUITE D-502
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3758
Mailing Address - Country:US
Mailing Address - Phone:859-277-8560
Mailing Address - Fax:859-277-8866
Practice Address - Street 1:1451 HARRODSBURG RD
Practice Address - Street 2:SUITE D-502
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3758
Practice Address - Country:US
Practice Address - Phone:859-277-8560
Practice Address - Fax:859-277-8866
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D55148Medicare UPIN
08BBXLGMedicare ID - Type Unspecified
KYK057902Medicare PIN