Provider Demographics
NPI:1245631902
Name:PORTER, MIRIAM ELAINE (AGACNP)
Entity type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:ELAINE
Last Name:PORTER
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 E CAMELOT PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-2718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 PARKWAY CIR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6362
Practice Address - Country:US
Practice Address - Phone:479-587-1700
Practice Address - Fax:479-587-1366
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004200207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology