Provider Demographics
NPI:1477908184
Name:PORTER, ANDREW E
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:E
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 OLD RIVER RD
Mailing Address - Street 2:APT 628
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-5802
Mailing Address - Country:US
Mailing Address - Phone:630-779-5986
Mailing Address - Fax:
Practice Address - Street 1:4975 FOOTE RD # 400
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8748
Practice Address - Country:US
Practice Address - Phone:440-443-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-01
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH1135037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program