Provider Demographics
NPI:1346841749
Name:HARRIS, MICK EMERSON (LAT, ATC, NREMT)
Entity type:Individual
Prefix:MR
First Name:MICK
Middle Name:EMERSON
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LAT, ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E MAGNOLIA AVE APT 119
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-4831
Mailing Address - Country:US
Mailing Address - Phone:316-650-2360
Mailing Address - Fax:
Practice Address - Street 1:188 S DONAHUE DRIVE
Practice Address - Street 2:121 NICHOLS CENTER
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36849-5513
Practice Address - Country:US
Practice Address - Phone:316-650-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0155-0083-2810146N00000X
AL26432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0155-0083-2810OtherNATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS
2000051386OtherATHLETIC TRAINING BOARD OF CERTIFICATION
AL2643OtherALABAMA BOARD OF ATHLETIC TRAINING