Provider Demographics
NPI:1538197306
Name:HARRIS, LARRY GENE (PA)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:GENE
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PA
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2145 HENRY TECKLENBURG DR STE 220
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5894
Practice Address - Country:US
Practice Address - Phone:843-723-8823
Practice Address - Fax:843-606-8059
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA751363AM0700X
SC363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0058PAMedicaid
SCGP5004OtherMEDICAID GROUP #
SCP00648626OtherRAILROAD MEDICARE ID
SC5551OtherMEDICARE GROUP #
SCGP5005OtherMEDICAID GROUP #
SCGP5007OtherMEDICAID GROUP #
SC0058PAMedicaid
SCAA30289223Medicare PIN
SC0058PAMedicaid