Provider Demographics
NPI:1306929252
Name:HARRIS, JOHN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2005
Mailing Address - Country:US
Mailing Address - Phone:509-254-1237
Mailing Address - Fax:
Practice Address - Street 1:1353 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2005
Practice Address - Country:US
Practice Address - Phone:509-254-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000040535208000000X
MT11916208000000X
MDD98218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8128498Medicaid
ID002384400Medicaid
WA49804OtherWA LABOR & INDUSTRIES
IDE89970Medicare UPIN
WA8128498Medicaid