Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 11614 | MN |
NPI | 1073157863 |
---|---|
Provider Name | Heather Porter |
First Address | Minneapolis, MN 55417-2234 |
Second Address | Minneapolis, MN 55404-1025 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/11/2019 |
Last Update Date | 05/11/2019 |