MEDICARE: MR. MICHAEL PORTER II RN

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	163W00000X	Registered Nurse	201192-30	WI

General Provider Information

NPI Number	:	1194180208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL PORTER II RN

Provider Business Mailing Address
First Line	:	2632A N BARTLETT AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-3501
Country	:	US
Telephone Number	:	414-975-0254
Fax Number	:

Provider Business Practice Location Address
First Line	:	2632A N BARTLETT AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-3501
Country	:	US
Telephone Number	:	414-975-0254
Fax Number	:

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

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	12/17/2015

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