Provider Demographics
NPI:1740238328
Name:PORTT, JAMES COOK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:COOK
Last Name:PORTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4212 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5319
Mailing Address - Country:US
Mailing Address - Phone:602-263-1508
Mailing Address - Fax:602-263-1617
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:INDIAN HEALTH SVC FEDERAL EMERGENCY RM
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:480-882-6359
Practice Address - Fax:480-882-4389
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ27674Medicare PIN
AZS95209Medicare UPIN