Healthcare Provider Details

I. General information

NPI: 1740238328
Provider Name (Legal Business Name): JAMES COOK PORTT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST INDIAN HEALTH SVC FEDERAL EMERGENCY RM
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-6359
  • Fax: 480-882-4389
Mailing address:
  • Phone: 602-263-1508
  • Fax: 602-263-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1565
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: