Provider Demographics
NPI:1851971931
Name:PORTER, CHANIKA WIDARSANIE (DO)
Entity type:Individual
Prefix:
First Name:CHANIKA
Middle Name:WIDARSANIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 LEBANON CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:WEST MIFFLIN
Mailing Address - State:PA
Mailing Address - Zip Code:15122-2461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2027 LEBANON CHURCH RD
Practice Address - Street 2:
Practice Address - City:WEST MIFFLIN
Practice Address - State:PA
Practice Address - Zip Code:15122-2461
Practice Address - Country:US
Practice Address - Phone:412-655-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS024037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine