Provider Demographics
NPI:1063584449
Name:PORTER, STEPHEN TROY (CRNA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:TROY
Last Name:PORTER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20641 S 196TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-6242
Mailing Address - Country:US
Mailing Address - Phone:618-322-4507
Mailing Address - Fax:
Practice Address - Street 1:135 S POWER RD STE 110
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5245
Practice Address - Country:US
Practice Address - Phone:480-745-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0827367500000X
IL209006282367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered