Healthcare Provider Details

I. General information

NPI: 1003103003
Provider Name (Legal Business Name): CARRIE KRAEGER PORTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE ELIZABETH PORTER

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-6666
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA063198
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: