Provider Demographics
NPI:1871849133
Name:PORTER, DOROTHY WHATLEY (PA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:WHATLEY
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:JEAN
Other - Last Name:WHATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-483-5826
Mailing Address - Fax:904-265-6409
Practice Address - Street 1:3635 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2300
Practice Address - Country:US
Practice Address - Phone:386-788-1242
Practice Address - Fax:386-756-8802
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106692363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006441000Medicaid
FLY0CE7OtherBCBS
GK243ZMedicare PIN