Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 2019022806 | MO |
Y | 111NI0900X | Internist | 2019022806 | MO |
NPI | 1003477522 |
---|---|
Provider Name | Tyler Porter |
First Address | Columbia, MO 65201-5276 |
Second Address | Columbia, MO 65201-5276 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2019 |
Last Update Date | 25/06/2019 |