Provider Demographics
NPI:1477863322
Name:PORTER, DOUGLAS ASHLEY (M-PAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ASHLEY
Last Name:PORTER
Suffix:
Gender:M
Credentials:M-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 LYLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:TN
Mailing Address - Zip Code:37191-8232
Mailing Address - Country:US
Mailing Address - Phone:931-542-6193
Mailing Address - Fax:
Practice Address - Street 1:3110 LYLEWOOD RD
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:TN
Practice Address - Zip Code:37191-8232
Practice Address - Country:US
Practice Address - Phone:931-542-6193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant