Provider Demographics
NPI:1083082804
Name:PORTER, PAUL WALLACE (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WALLACE
Last Name:PORTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:MICHAEL
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2248 PARK BLVD.
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306
Mailing Address - Country:US
Mailing Address - Phone:650-328-4411
Mailing Address - Fax:
Practice Address - Street 1:2248 PARK BLVD.
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306
Practice Address - Country:US
Practice Address - Phone:650-328-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33060111NR0400X, 111NX0100X, 111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NX0100XChiropractic ProvidersChiropractorOccupational Health