Provider Demographics
NPI:1871535989
Name:HARRIS, LEONARD RUSSELL (PA)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:RUSSELL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 GRASS VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-4533
Mailing Address - Country:US
Mailing Address - Phone:530-885-0344
Mailing Address - Fax:
Practice Address - Street 1:275 GRASS VALLEY HWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-4533
Practice Address - Country:US
Practice Address - Phone:530-885-0344
Practice Address - Fax:530-885-8967
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA165210Medicaid
CA0PA165210Medicaid