Provider Demographics
NPI: | 1013932425 |
---|---|
Name: | PORTER, LEE W (NP, CNS-PMH) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | LEE |
Middle Name: | W |
Last Name: | PORTER |
Suffix: | |
Gender: | M |
Credentials: | NP, CNS-PMH |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 65 DIVISION AVE UNIT 299 |
Mailing Address - Street 2: | |
Mailing Address - City: | EUGENE |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97404-2485 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 541-896-1555 |
Mailing Address - Fax: | 888-562-3550 |
Practice Address - Street 1: | 5305 RIVER RD N STE B |
Practice Address - Street 2: | |
Practice Address - City: | KEIZER |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97303-5324 |
Practice Address - Country: | US |
Practice Address - Phone: | 541-896-1555 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-13 |
Last Update Date: | 2022-12-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 202002489CNS-PP | 208VP0000X, 364SP0809X, 364SP0813X, 363LP0808X |
NC | 163552 | 2084N0600X |
OR | 201501835NP-PP | 363LA2200X, 364SP0808X, 364SP0811X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No | 2084N0600X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No | 364SP0808X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health |
No | 364SP0809X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Adult |
No | 364SP0811X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Chronically Ill |
No | 364SP0813X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Geropsychiatric |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 3072541580 | Other | PECOS PAC ID |
OR | I20160510002557 | Other | PECOS PAC ENROLLMENT ID |
NC | 131VX | Other | BLUE CROSS PROVIDER ID |
OR | 500709395 | Medicaid | |
NC | 131VX | Other | BLUE CROSS PROVIDER ID |