Basic Information
| Provider Information | |||||||||
| NPI: | 1336549419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAT | ||||||||
| FirstName: | KRISS HARRISON | ||||||||
| MiddleName: | PULGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106019000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2014 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN637932 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 0001198518 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.