Provider Demographics
NPI:1528441854
Name:BASIL-PORTER, AMANDA M (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:BASIL-PORTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:AJINE-BASIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:248-577-3313
Mailing Address - Fax:
Practice Address - Street 1:25631 LITTLE MACK AVE STE 205
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2108
Practice Address - Country:US
Practice Address - Phone:586-443-2380
Practice Address - Fax:586-443-2935
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057154363A00000X
MI5601009765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103194448Medicaid
419405Medicare PIN