Healthcare Provider Details

I. General information

NPI: 1063584449
Provider Name (Legal Business Name): STEPHEN TROY PORTER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 S POWER RD STE 110
MESA AZ
85206-5245
US

IV. Provider business mailing address

20641 S 196TH ST
QUEEN CREEK AZ
85142-6242
US

V. Phone/Fax

Practice location:
  • Phone: 480-745-8577
  • Fax:
Mailing address:
  • Phone: 618-322-4507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0827
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209006282
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: