Provider Demographics
NPI:1437925336
Name:PORTER, TYLER SHAWN (PT)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:SHAWN
Last Name:PORTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 CARDOVA DR
Mailing Address - Street 2:
Mailing Address - City:MAX MEADOWS
Mailing Address - State:VA
Mailing Address - Zip Code:24360-3651
Mailing Address - Country:US
Mailing Address - Phone:276-620-2465
Mailing Address - Fax:
Practice Address - Street 1:209 MADISON ST STE LL2
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2065
Practice Address - Country:US
Practice Address - Phone:703-299-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22776225100000X
VA2305216214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty