Provider Demographics
NPI:1568566503
Name:PORTER, POLLY ANN (PA-C, ATC)
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:ANN
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35731 DUNTHORPE LN
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-5225
Mailing Address - Country:US
Mailing Address - Phone:703-395-3885
Mailing Address - Fax:
Practice Address - Street 1:35731 DUNTHORPE LN
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-5225
Practice Address - Country:US
Practice Address - Phone:703-395-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001565363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA208062791Medicare PIN