Provider Demographics
NPI:1528289717
Name:PORTER, MARK WILKIN (CP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILKIN
Last Name:PORTER
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10381 ST ANDREWS CT
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:47630
Mailing Address - Country:US
Mailing Address - Phone:812-490-4449
Mailing Address - Fax:
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747
Practice Address - Country:US
Practice Address - Phone:812-450-2719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN800279-0971242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist