Healthcare Provider Details

I. General information

NPI: 1871116582
Provider Name (Legal Business Name): ALIA PORTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 STATE ST
AUGUSTA KS
67010-1126
US

IV. Provider business mailing address

1306 STATE ST
AUGUSTA KS
67010-1126
US

V. Phone/Fax

Practice location:
  • Phone: 316-617-4275
  • Fax:
Mailing address:
  • Phone: 316-775-9191
  • Fax: 316-775-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02389
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: