Provider Demographics
NPI:1083002570
Name:PORTER, ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:1404 RIVER PL STE 501
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5600
Practice Address - Country:US
Practice Address - Phone:770-848-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2677363A00000X
GA10769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant