Provider Demographics
NPI:1639574155
Name:PORTER, CAITLIN GRIFFIN (PA-C)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:GRIFFIN
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TOWER CT STE B
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3318
Mailing Address - Country:US
Mailing Address - Phone:847-224-0222
Mailing Address - Fax:
Practice Address - Street 1:25 TOWER CT STE B
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3318
Practice Address - Country:US
Practice Address - Phone:847-618-0730
Practice Address - Fax:847-224-0222
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085005224OtherSTATE LICENSE