Provider Demographics
NPI:1750561924
Name:PORTER, AMANDA LOGAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LOGAN
Last Name:PORTER
Suffix:
Gender:F
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 1:726 YORKLYN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-8744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:726 YORKLYN ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-0000
Practice Address - Country:US
Practice Address - Phone:302-234-5770
Practice Address - Fax:302-234-5777
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000603363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical