Basic Information
| Provider Information | |||||||||
| NPI: | 1124165972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1451 HARRODSBURG RD | ||||||||
| Address2: | SUITE D-502 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592778560 | ||||||||
| FaxNumber: | 8592778866 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 HARRODSBURG RD | ||||||||
| Address2: | SUITE D-502 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592778560 | ||||||||
| FaxNumber: | 8592778866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 12/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41917 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.