Provider Demographics
NPI:1801826094
Name:PORTER, ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
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 1:5424 E SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3621
Mailing Address - Country:US
Mailing Address - Phone:480-654-6200
Mailing Address - Fax:480-654-6214
Practice Address - Street 1:5424 E SOUTHERN AVE
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3621
Practice Address - Country:US
Practice Address - Phone:480-654-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ913956Medicaid
AZ913956Medicaid