Provider Demographics
NPI:1881679306
Name:PORTER, SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
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 1:400 LIBERTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2446
Mailing Address - Country:US
Mailing Address - Phone:910-738-8060
Mailing Address - Fax:910-671-3600
Practice Address - Street 1:400 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2446
Practice Address - Country:US
Practice Address - Phone:910-738-8060
Practice Address - Fax:910-671-3600
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1881679306Medicaid
NC102878OtherNC LICENSE