Provider Demographics
NPI:1376828780
Name:PORTER, GLEN ALAN (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ALAN
Last Name:PORTER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 E CAROL ANN WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3820
Mailing Address - Country:US
Mailing Address - Phone:602-769-2714
Mailing Address - Fax:
Practice Address - Street 1:6611 W BELL RD
Practice Address - Street 2:(INSIDE FRYS)
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3607
Practice Address - Country:US
Practice Address - Phone:623-334-2953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily