Provider Demographics
NPI:1144862970
Name:HARRIS, BOBBY
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-1258
Mailing Address - Country:US
Mailing Address - Phone:931-253-1110
Mailing Address - Fax:
Practice Address - Street 1:1008 AZALEA DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2499
Practice Address - Country:US
Practice Address - Phone:601-509-2584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily