Provider Demographics
NPI:1548728611
Name:HARRISON, THOMAS PATRICK (LPN)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:PATRICK
Last Name:HARRISON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 137TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-9705
Mailing Address - Country:US
Mailing Address - Phone:616-322-9574
Mailing Address - Fax:
Practice Address - Street 1:1215 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3849
Practice Address - Country:US
Practice Address - Phone:616-742-0351
Practice Address - Fax:616-742-0370
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703098125164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse