Provider Demographics
NPI:1336183037
Name:PORTER, JOHN RICHARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:PORTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7024 CAMEO DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3417
Mailing Address - Country:US
Mailing Address - Phone:253-582-3555
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:MAMC FAMILY MED DEPT
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant