Provider Demographics
NPI:1871359273
Name:HARRIS, MARIO MARKELL
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:MARKELL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17136 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50323-2790
Mailing Address - Country:US
Mailing Address - Phone:515-577-1832
Mailing Address - Fax:
Practice Address - Street 1:17136 LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50323-2790
Practice Address - Country:US
Practice Address - Phone:515-577-1832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7548080172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver