Provider Demographics
NPI:1386725703
Name:PORTER, TIFFANY ETTA (CRNA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ETTA
Last Name:PORTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINS FERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43935-1648
Mailing Address - Country:US
Mailing Address - Phone:740-633-1100
Mailing Address - Fax:
Practice Address - Street 1:68377 STEWART DR STE 202
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-1718
Practice Address - Country:US
Practice Address - Phone:740-699-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06655367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH207804OtherMEDICARE PTAN
WV2603432000Medicaid
WV2603432000Medicaid