Provider Demographics
NPI:1992144943
Name:PORTER, DEVIN LANE (PA-C)
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:LANE
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0159
Mailing Address - Country:US
Mailing Address - Phone:480-433-0371
Mailing Address - Fax:
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7831
Practice Address - Country:US
Practice Address - Phone:928-537-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant