Provider Demographics
NPI:1306507157
Name:PORTER, PHILIP W (PT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:W
Last Name:PORTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1910
Mailing Address - Country:US
Mailing Address - Phone:520-322-6274
Mailing Address - Fax:520-509-4496
Practice Address - Street 1:6264 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5882
Practice Address - Country:US
Practice Address - Phone:520-884-0001
Practice Address - Fax:520-884-0199
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225100000X
AZ32180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109503Medicaid
AZ32180OtherLPT LICENSE