MEDICARE: MR. MESIAH O'MAR PORTER JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	83-1469962	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN242562	OTHER	GA	GEORGIA PROFESSIONAL LICENSING
2	2018003411	OTHER	GA	AMERICAN NURSES CREDENTIALING CENTER

General Provider Information

NPI Number	:	1134783368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MESIAH O'MAR PORTER JR.

Provider Business Mailing Address
First Line	:	3085 BENTWOOD DR
Second Line	:
City	:	WAYCROSS
State	:	GA
Zip	:	31503-4117
Country	:	US
Telephone Number	:	912-288-1024
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 SATELLITE BLVD STE 3
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-4913
Country	:	US
Telephone Number	:	770-614-6266
Fax Number	:	770-623-9949

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	04/23/2019

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