Provider Demographics
NPI:1043841216
Name:PORTER, MEGAN YVETTE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:YVETTE
Last Name:PORTER
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 1:4030 N CENTRAL EXPY APT 376
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-3252
Mailing Address - Country:US
Mailing Address - Phone:904-437-2725
Mailing Address - Fax:
Practice Address - Street 1:11722 MARSH LN STE 372
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-2682
Practice Address - Country:US
Practice Address - Phone:817-893-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF01200679363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty