Provider Demographics
NPI:1992888770
Name:PORTER, MICHAEL SHAWN (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:PORTER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 DRY RUN RD
Mailing Address - Street 2:
Mailing Address - City:BEECH CREEK
Mailing Address - State:PA
Mailing Address - Zip Code:16822-8028
Mailing Address - Country:US
Mailing Address - Phone:570-726-2295
Mailing Address - Fax:
Practice Address - Street 1:401 SUSQUEHANNA AVE
Practice Address - Street 2:LOCK HAVEN UNIVERSITY
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745
Practice Address - Country:US
Practice Address - Phone:570-893-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART-000866-A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer