Basic Information
| Provider Information | |||||||||
| NPI: | 1366494965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841390 | ||||||||
| FaxNumber: | 7043841063 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 RANDOLPH RD | ||||||||
| Address2: | SUITE 1010 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841390 | ||||||||
| FaxNumber: | 7043841063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 300302 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | 300302 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 166746 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7005303 | 05 | NC | MEDICAID | NP1935 | 05 | SC | MEDICAID | 1366494965 | 05 | NC | MEDICAID |