Healthcare Provider Details

I. General information

NPI: 1558562629
Provider Name (Legal Business Name): ANGEL PORTER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 01/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 FERN VALLEY RD
LOUISVILLE KY
40213-3529
US

IV. Provider business mailing address

PO BOX 950248
LOUISVILLE KY
40295-0248
US

V. Phone/Fax

Practice location:
  • Phone: 502-964-4889
  • Fax:
Mailing address:
  • Phone: 502-489-5730
  • Fax: 502-489-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA637
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberPA637
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: