Provider Demographics
NPI:1518900802
Name:PORTER, RONALD D (CRNA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:PORTER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 STANAFORD RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3142
Mailing Address - Country:US
Mailing Address - Phone:304-255-3436
Mailing Address - Fax:
Practice Address - Street 1:327 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9006
Practice Address - Country:US
Practice Address - Phone:681-342-1610
Practice Address - Fax:681-342-1626
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21431367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706470OtherMSBCBS GROUP
WV3810006746Medicaid
WVDF0767OtherRR MEDICARE
WV205542387OtherAAP TRI CARE NUMBER
WV27005299700OtherTRICARE
WV270052997004OtherTRICARE
WV270052997004OtherWORKERS COMP
WV0067342000Medicaid
WV8226335OtherMEDICARE PTAN
WV1054827OtherWORKERS COMP INDIVIDUAL
WVP00211135OtherRR MEDICARE
WV001713627OtherBCBS AAP NUMBER
WV001713627OtherMSBCBS
WV001907661OtherMSBCBS
WV0207026000Medicaid
WV27005299701OtherWORKERS COMP
WVDA0096OtherRR MEDICARE
WVP00407274OtherRR MEDICARE
WV20554238700OtherWORKERS COMP
WV001713627OtherBCBS AAP NUMBER
WVP00211135OtherRR MEDICARE
WV205542387OtherAAP TRI CARE NUMBER
WV0207026000Medicaid