1295718013 NPI number — WILLIAM ANTHONY HARRISON MD

Table of content: WILLIAM ANTHONY HARRISON MD (NPI 1295718013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295718013 NPI number — WILLIAM ANTHONY HARRISON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRISON
Provider First Name:
WILLIAM
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1295718013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82003-7020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-996-1560
Provider Business Mailing Address Fax Number:
307-996-1565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 E 20TH ST
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001-3859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-996-1560
Provider Business Practice Location Address Fax Number:
307-996-1565
Provider Enumeration Date:
11/25/2005

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: 207R00000X , with the licence number:  5769A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5769A . This is a "STATE LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 110746100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 710WH95 . This is a "SUBSTANCE CONTROL" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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