Provider Demographics
NPI:1902688138
Name:PORTER, BRAXTON
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:PORTER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-9073
Mailing Address - Country:US
Mailing Address - Phone:801-866-4791
Mailing Address - Fax:
Practice Address - Street 1:435 W CRYSTAL ST.
Practice Address - Street 2:SUITE 300
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701
Practice Address - Country:US
Practice Address - Phone:406-496-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT148617363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical