Provider Demographics
NPI:1003393190
Name:PORATH, DEVYN
Entity Type:Individual
Prefix:
First Name:DEVYN
Middle Name:
Last Name:PORATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15739 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1323
Mailing Address - Country:US
Mailing Address - Phone:734-308-7224
Mailing Address - Fax:
Practice Address - Street 1:39555 W 10 MILE RD STE 302
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2950
Practice Address - Country:US
Practice Address - Phone:248-426-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315094078363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical