1871504076 NPI number — JUDITH KAY HARRIS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871504076 NPI number — JUDITH KAY HARRIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
JUDITH
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TUCKER
Provider Other First Name:
JUDITH
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871504076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7348 W 21ST ST N
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67205-1765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-721-4828
Provider Business Mailing Address Fax Number:
316-721-4844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7348 W 21ST ST N
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67205-1765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-721-4828
Provider Business Practice Location Address Fax Number:
316-721-4844
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  44009 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100363930C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161002 . This is a "BC/BS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 500021112 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 13309 . This is a "PREFERRED HEALTH SYSTEMS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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