Provider Demographics
NPI:1174292445
Name:PORCHE, DALTON JAMES
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:JAMES
Last Name:PORCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 BELLEVUE RD APT F2
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-2715
Mailing Address - Country:US
Mailing Address - Phone:770-549-1002
Mailing Address - Fax:
Practice Address - Street 1:315 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-5030
Practice Address - Country:US
Practice Address - Phone:615-868-6503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN258274163W00000X
GA136268367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse