Healthcare Provider Details

I. General information

NPI: 1437514718
Provider Name (Legal Business Name): MICHELLE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 S TAMIAMI TRL
SARASOTA FL
34239-3806
US

IV. Provider business mailing address

2255 S TAMIAMI TRL
SARASOTA FL
34239-3806
US

V. Phone/Fax

Practice location:
  • Phone: 941-366-8897
  • Fax:
Mailing address:
  • Phone: 941-366-8897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.004514
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9111489
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: