Provider Demographics
NPI:1467827402
Name:PORTER, SURRELL
Entity Type:Individual
Prefix:MS
First Name:SURRELL
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1287 GEORGIA HIGHWAY 138 SPUR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236
Mailing Address - Country:US
Mailing Address - Phone:770-473-0038
Mailing Address - Fax:770-471-4290
Practice Address - Street 1:1287 GEORGIA HIGHWAY 138 SPUR
Practice Address - Street 2:SUITE 8
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:770-473-0038
Practice Address - Fax:770-471-4290
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN181538363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care