Provider Demographics
NPI:1487624623
Name:PORTER, WENDELL KEITH (PA-C)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:KEITH
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 1:1105 OAK CLUSTER DR
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-6079
Mailing Address - Country:US
Mailing Address - Phone:865-908-3636
Mailing Address - Fax:865-908-3644
Practice Address - Street 1:1105 OAK CLUSTER DR
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6079
Practice Address - Country:US
Practice Address - Phone:865-908-3636
Practice Address - Fax:865-908-3644
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPA:1040254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0626PAMedicaid
SCAA26468037Medicare UPIN