Healthcare Provider Details

I. General information

NPI: 1083082804
Provider Name (Legal Business Name): PAUL WALLACE PORTER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DR. PAUL MICHAEL COOK

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 08/14/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2248 PARK BLVD.
PALO ALTO CA
94306
US

IV. Provider business mailing address

2248 PARK BLVD.
PALO ALTO CA
94306
US

V. Phone/Fax

Practice location:
  • Phone: 650-328-4411
  • Fax:
Mailing address:
  • Phone: 650-328-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number33060
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number33060
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number33060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: