Provider Demographics
NPI:1497056428
Name:PORTER, CASSANDRA E (NP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:E
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4634 HILLS AND DALES RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-1510
Mailing Address - Country:US
Mailing Address - Phone:330-477-0255
Mailing Address - Fax:330-479-0392
Practice Address - Street 1:4634 HILLS AND DALES RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1510
Practice Address - Country:US
Practice Address - Phone:330-493-1480
Practice Address - Fax:330-493-6805
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP11954363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3144023Medicaid
NP38451Medicare PIN