Provider Demographics
NPI:1386780237
Name:HARRIS, CHARLES F (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15240
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-5240
Mailing Address - Country:US
Mailing Address - Phone:307-733-8002
Mailing Address - Fax:307-733-0032
Practice Address - Street 1:982 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-733-8002
Practice Address - Fax:307-733-0032
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY76363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109651600Medicaid
WYW307446Medicare PIN
WYR04584Medicare UPIN
WYW306748Medicare PIN