Basic Information
| Provider Information | |||||||||
| NPI: | 1013505577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2794 BELLMORE AVE | ||||||||
| Address2: | |||||||||
| City: | BELLMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117104312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165571541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1345 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101050302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129130828 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2021 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 026166 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.