Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223X0400X | Orthodontists | 0442000250 | VA |
Y | 1223X0400X | Orthodontists | DE60936198 | WA |
NPI | 1003272444 |
---|---|
Provider Name | Jason Porter |
First Address | Sunnyside, WA 98944-2478 |
Second Address | Sunnyside, WA 98944-2478 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2016 |
Last Update Date | 22/05/2019 |