Provider Demographics
NPI:1184354110
Name:PORTER, PAUL ANTHONY (CRNP)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:PORTER
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 OUTBACK DR
Mailing Address - Street 2:
Mailing Address - City:WEDOWEE
Mailing Address - State:AL
Mailing Address - Zip Code:36278-4075
Mailing Address - Country:US
Mailing Address - Phone:256-557-8397
Mailing Address - Fax:
Practice Address - Street 1:1201 22ND ST N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35234-2726
Practice Address - Country:US
Practice Address - Phone:205-251-5271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-132215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner