1780169276 NPI number — MR. BRENT AUSTIN HARRIS AGACNP-C

Table of content: MR. BRENT AUSTIN HARRIS AGACNP-C (NPI 1780169276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780169276 NPI number — MR. BRENT AUSTIN HARRIS AGACNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
BRENT
Provider Middle Name:
AUSTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780169276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 14611
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29610-4611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-306-0966
Provider Business Mailing Address Fax Number:
864-306-2544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3523 PELHAM RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-4191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-306-0966
Provider Business Practice Location Address Fax Number:
864-306-0966
Provider Enumeration Date:
10/01/2018

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: 363LA2100X , with the licence number:  22267 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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