Provider Demographics
NPI:1386700086
Name:HARRIS, GREGORY DEON
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DEON
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 GILLIONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3735
Mailing Address - Country:US
Mailing Address - Phone:229-435-3922
Mailing Address - Fax:229-435-3945
Practice Address - Street 1:1716 GILLIONVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3735
Practice Address - Country:US
Practice Address - Phone:229-435-3922
Practice Address - Fax:229-435-3945
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047-R-0007374U00000X, 376J00000X, 376K00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered374U00000XNursing Service Related ProvidersHome Health Aide
Not Answered376J00000XNursing Service Related ProvidersHomemaker
Not Answered376K00000XNursing Service Related ProvidersNurse's Aide
Not Answered3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000696814CMedicaid
GA000696814AMedicaid
GA000696814EMedicaid