Provider Demographics
NPI:1821061862
Name:PORTER, WALTER NATHANIEL (MD)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:NATHANIEL
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 W 126TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-1353
Mailing Address - Country:US
Mailing Address - Phone:913-548-0839
Mailing Address - Fax:
Practice Address - Street 1:2312 W 126TH ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-1353
Practice Address - Country:US
Practice Address - Phone:913-469-1814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9867207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC52162Medicare UPIN