Provider Demographics
NPI:1033482336
Name:PORTER, KATIE M (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PENNSYLVANIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4754
Mailing Address - Country:US
Mailing Address - Phone:575-623-9101
Mailing Address - Fax:
Practice Address - Street 1:400 N PENNSYLVANIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4754
Practice Address - Country:US
Practice Address - Phone:575-623-9101
Practice Address - Fax:575-623-3020
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI881-392255A2300X
NMPA2014-0086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer