Provider Demographics
NPI:1154831642
Name:PORTER, DAVID VAUGHN JR (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:VAUGHN
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1010 CARONDELET DR STE 121
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4859
Mailing Address - Country:US
Mailing Address - Phone:816-912-2100
Mailing Address - Fax:636-438-0430
Practice Address - Street 1:2316 E MEYER BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1136
Practice Address - Country:US
Practice Address - Phone:816-912-2100
Practice Address - Fax:636-438-0430
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2024-03-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2017036354363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical