Provider Demographics
NPI:1417024910
Name:PORTER DOSTI, MANDY LYNN (MS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:MANDY
Middle Name:LYNN
Last Name:PORTER DOSTI
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 PRESTON CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-4100
Mailing Address - Country:US
Mailing Address - Phone:608-236-4248
Mailing Address - Fax:
Practice Address - Street 1:2315 E MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2939
Practice Address - Country:US
Practice Address - Phone:262-532-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2050023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant