Provider Demographics
NPI:1154569010
Name:NILSSON, PORTER MIKEL (MSOM, LAC)
Entity type:Individual
Prefix:MR
First Name:PORTER
Middle Name:MIKEL
Last Name:NILSSON
Suffix:
Gender:M
Credentials:MSOM, LAC
Other - Prefix:MR
Other - First Name:NILS
Other - Middle Name:PORTER
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOM LIC AC
Mailing Address - Street 1:610 N NANSEMOND ST APT 4
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-1540
Mailing Address - Country:US
Mailing Address - Phone:804-938-6457
Mailing Address - Fax:
Practice Address - Street 1:3122 W CARY ST STE 220
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-3500
Practice Address - Country:US
Practice Address - Phone:804-938-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000440171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty