MEDICARE: MICHAEL LAWRENCE 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	363AS0400X	Surgical Physician Assistant	4268	AZ
2	363AS0400X	Surgical Physician Assistant	PA06738	TX

General Provider Information

NPI Number	:	1851541270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LAWRENCE PORTER PA-C

Provider Business Mailing Address
First Line	:	6752 BRITTANY PARK CT
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-3823
Country	:	US
Telephone Number	:	972-757-3410
Fax Number	:

Provider Business Practice Location Address
First Line	:	6752 BRITTANY PARK CT
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-3823
Country	:	US
Telephone Number	:	972-757-3410
Fax Number	:

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

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	10/16/2012

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