Basic Information
| Provider Information | |||||||||
| NPI: | 1336458959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TRUE | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | SUITE A-540 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592586760 | ||||||||
| FaxNumber: | 8592586512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | SUITE A-540 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592586760 | ||||||||
| FaxNumber: | 8592586512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA1598 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7100144660 | 05 | KY | MEDICAID | PA1598 | 01 | KY | STATE LICENSURE | OTHER |