Healthcare Provider Details

I. General information

NPI: 1962458828
Provider Name (Legal Business Name): ANDREW S. T. PORTER D.O., FAAFP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N EMPORIA ST
WICHITA KS
67214-3707
US

IV. Provider business mailing address

PO BOX 1897
WICHITA KS
67201-1897
US

V. Phone/Fax

Practice location:
  • Phone: 316-858-3460
  • Fax: 316-858-3458
Mailing address:
  • Phone: 316-268-8131
  • Fax: 316-291-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-31673
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number05-31673
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: