Provider Demographics
NPI:1841546520
Name:PORTER, SUSAN CAROLE (MT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CAROLE
Last Name:PORTER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 6TH AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:WOLF POINT
Mailing Address - State:MT
Mailing Address - Zip Code:59201
Mailing Address - Country:US
Mailing Address - Phone:406-653-5628
Mailing Address - Fax:406-653-1177
Practice Address - Street 1:550 SIXTH AV N
Practice Address - Street 2:
Practice Address - City:WOLF POINT
Practice Address - State:MT
Practice Address - Zip Code:59201-0729
Practice Address - Country:US
Practice Address - Phone:406-653-5628
Practice Address - Fax:406-653-1177
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT805246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist