Provider Demographics
NPI:1508541459
Name:PORTING, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:PORTING
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 1:200 W DOUGLAS AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3002
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:
Practice Address - Street 1:2040 HUTTON RD STE 104
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-4566
Practice Address - Country:US
Practice Address - Phone:913-725-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-05910225200000X
KS1404119225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant