Provider Demographics
NPI:1679598353
Name:PORTER, NIKKI B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:B
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:1534 ELIZABETH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4531
Mailing Address - Country:US
Mailing Address - Phone:318-629-5001
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-635-3052
Practice Address - Fax:318-635-3072
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-07-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA200061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5F600P716Medicare ID - Type Unspecified
LA1316458Medicaid
LAQ57791Medicare UPIN
LA348535YJS0Medicare PIN