Provider Demographics
NPI:1538542816
Name:HARRIS, MARK TODD (APRN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:TODD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2237
Mailing Address - Country:US
Mailing Address - Phone:502-718-5101
Mailing Address - Fax:
Practice Address - Street 1:1505 S 7TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1710
Practice Address - Country:US
Practice Address - Phone:502-637-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-03
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily