Provider Demographics
NPI:1265780258
Name:PORTER, JOE (PA)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2416
Mailing Address - Country:US
Mailing Address - Phone:435-789-6677
Mailing Address - Fax:435-789-6678
Practice Address - Street 1:872 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2416
Practice Address - Country:US
Practice Address - Phone:435-789-6677
Practice Address - Fax:435-789-6677
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7585928-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant