Provider Demographics
NPI:1790364461
Name:PORTER, HAYDEN EDWARD
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:EDWARD
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 S CLEMENTINE ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6013
Mailing Address - Country:US
Mailing Address - Phone:760-224-9277
Mailing Address - Fax:
Practice Address - Street 1:1822 S CLEMENTINE ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6013
Practice Address - Country:US
Practice Address - Phone:760-224-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program