Provider Demographics
NPI:1508940230
Name:PORTER, PAM A (PT)
Entity Type:Individual
Prefix:MS
First Name:PAM
Middle Name:A
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:AL
Mailing Address - Zip Code:36559-0183
Mailing Address - Country:US
Mailing Address - Phone:251-621-6865
Mailing Address - Fax:251-621-6891
Practice Address - Street 1:1207 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4420
Practice Address - Country:US
Practice Address - Phone:251-621-6865
Practice Address - Fax:251-621-6891
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH14592251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51033114OtherBLUE CROSS BLUE SHIELD