Provider Demographics
NPI:1811595150
Name:PORTER, LISA (MS, HTL(ASCP))
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:MS, HTL(ASCP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 SIMMS ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4359
Mailing Address - Country:US
Mailing Address - Phone:708-368-5055
Mailing Address - Fax:
Practice Address - Street 1:1611 SIMMS ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4359
Practice Address - Country:US
Practice Address - Phone:708-368-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246QH0600X, 246QL0900X, 246QL0900X, 246RH0600X
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
No246QH0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHistology
No376K00000XNursing Service Related ProvidersNurse's Aide
No246RH0600XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyHistology