Provider Demographics
NPI:1144909862
Name:SMITH, HARRISON
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:
Last Name:SMITH
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2003 STULTS RD STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-1291
Practice Address - Country:US
Practice Address - Phone:260-356-5424
Practice Address - Fax:260-358-2090
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004157A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant