Provider Demographics
NPI:1558503615
Name:HARRIS, DESHAWN ANTONIO SR (APRN)
Entity type:Individual
Prefix:MR
First Name:DESHAWN
Middle Name:ANTONIO
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:329 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4332
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:
Practice Address - Street 1:106 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45344-1835
Practice Address - Country:US
Practice Address - Phone:937-667-1122
Practice Address - Fax:419-225-8878
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017379363LF0000X
OHAPRN.CNP.026018363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0385393Medicaid