Basic Information
| Provider Information | |||||||||
| NPI: | 1962436782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41889 E. FLORIDA AVE. | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516528700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2390 E FLORIDA AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925444711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514144011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-103486 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | G175785 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036103486 | 05 | IL | MEDICAID | G175785 | 05 | CA | MEDICAID |