Provider Demographics
NPI:1023379716
Name:PORTER, CAROL ELAINE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ELAINE
Last Name:PORTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:CAROL
Other - Middle Name:ELAINE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:P.O. BOX 8225
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-0225
Mailing Address - Country:US
Mailing Address - Phone:304-399-0137
Mailing Address - Fax:304-399-0138
Practice Address - Street 1:2900 FIRST AVE
Practice Address - Street 2:SUITE 6019
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-399-0137
Practice Address - Fax:304-399-0138
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV31632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered