Provider Demographics
NPI:1255588364
Name:PORTER, BRITTANY L (PAC)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:L
Other - Last Name:BRONSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:252 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1828
Practice Address - Country:US
Practice Address - Phone:262-767-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2308-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43025900Medicaid
WI1083028OtherPAC CERTIFICATION
WI058754176Medicare PIN