Provider Demographics
NPI:1497453955
Name:PORTER, WACO C
Entity Type:Individual
Prefix:MR
First Name:WACO
Middle Name:C
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 1:6713 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-6140
Mailing Address - Country:US
Mailing Address - Phone:816-809-8086
Mailing Address - Fax:
Practice Address - Street 1:11032 S GREEN RD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5657
Practice Address - Country:US
Practice Address - Phone:816-547-9654
Practice Address - Fax:816-832-2874
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant