Provider Demographics
NPI:1841068038
Name:HARRIS, KERISSA TAYLOR
Entity type:Individual
Prefix:
First Name:KERISSA
Middle Name:TAYLOR
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E BROADWAY STE 240
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8022
Mailing Address - Country:US
Mailing Address - Phone:573-815-8145
Mailing Address - Fax:
Practice Address - Street 1:1601 E BROADWAY STE 240
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8022
Practice Address - Country:US
Practice Address - Phone:573-815-8145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2024-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant