Provider Demographics
NPI:1669042198
Name:CHILLIS, PORSHA ADELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:PORSHA
Middle Name:ADELLE
Last Name:CHILLIS
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 1:1001 12TH AVE STE 171
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-576-6500
Mailing Address - Fax:
Practice Address - Street 1:1001 12TH AVE STE 171
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-576-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant