MEDICARE: MRS. KELLY JAY PORTER PA-C

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1205598042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY JAY PORTER PA-C

Provider Business Mailing Address
First Line	:	2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-0001
Country	:	US
Telephone Number	:	910-907-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	6 TEEPEE CT
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-4408
Country	:	US
Telephone Number	:	347-454-4643
Fax Number	:

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

Provider Enumeration Date	:	10/08/2021
Last Update Date	:	02/04/2026

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