Provider Demographics
NPI:1720365331
Name:PORTER, CASSANDRA CHRISTINE (PA)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:CHRISTINE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:657-763-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X363A00000X
IN10001355A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14730081Medicaid
COPA.0004348OtherP A LICENSE
IN300097298Medicaid