Provider Demographics
NPI:1902978034
Name:HARRIS, SANDRA RAE (LMP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:RAE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24223 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-3881
Mailing Address - Country:US
Mailing Address - Phone:206-878-2872
Mailing Address - Fax:
Practice Address - Street 1:24223 9TH AVE S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-3881
Practice Address - Country:US
Practice Address - Phone:206-878-2872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012501173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00012501OtherSTATE LICENSE
WA6019476590010001OtherUBI NUMBER