Provider Demographics
NPI:1134783368
Name:PORTER, MESIAH O'MAR JR
Entity type:Individual
Prefix:MR
First Name:MESIAH
Middle Name:O'MAR
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MESIAH
Other - Middle Name:O'MAR
Other - Last Name:PORTER
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MSN, APRN, FNP-BC
Mailing Address - Street 1:3085 BENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-4117
Mailing Address - Country:US
Mailing Address - Phone:912-288-1024
Mailing Address - Fax:
Practice Address - Street 1:1611 SATELLITE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4913
Practice Address - Country:US
Practice Address - Phone:770-614-6266
Practice Address - Fax:770-623-9949
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83-1469962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN242562OtherGEORGIA PROFESSIONAL LICENSING
GA2018003411OtherAMERICAN NURSES CREDENTIALING CENTER