Provider Demographics
NPI:1366801870
Name:PORTER, KIRK (PA-C)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E MATTHEWS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4315
Mailing Address - Country:US
Mailing Address - Phone:870-931-4442
Mailing Address - Fax:870-802-0205
Practice Address - Street 1:1107 E MATTHEWS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4315
Practice Address - Country:US
Practice Address - Phone:870-931-4442
Practice Address - Fax:870-802-0205
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2016-011363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR212903795Medicaid
AR478609ZTQWMedicare PIN