Provider Demographics
NPI:1710010905
Name:PORTER, GARY KEITH JR (MS, ATC, LAT, CEAS)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:KEITH
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:MS, ATC, LAT, CEAS
Other - Prefix:
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Mailing Address - Street 1:999 SW 16TH AVE
Mailing Address - Street 2:105
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-0425
Mailing Address - Country:US
Mailing Address - Phone:352-514-4761
Mailing Address - Fax:
Practice Address - Street 1:222 E UNIVERSITY AVE
Practice Address - Street 2:STATION 44
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5456
Practice Address - Country:US
Practice Address - Phone:352-334-5000
Practice Address - Fax:352-334-3185
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAL 13352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer