Provider Demographics
NPI:1366278269
Name:HARRIS, SAMUEL (RN)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11008 DOUBLE EAGLE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6559
Mailing Address - Country:US
Mailing Address - Phone:505-440-5498
Mailing Address - Fax:
Practice Address - Street 1:11008 DOUBLE EAGLE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6559
Practice Address - Country:US
Practice Address - Phone:505-440-5498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-79113163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care