Healthcare Provider Details

I. General information

NPI: 1184894354
Provider Name (Legal Business Name): GARY S. PORTER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 B SHEPHERDS SQUARD
DIAMONDHEAD MS
39525
US

IV. Provider business mailing address

149 DRINKWATER RD
BAY ST LOUIS MS
39520-1658
US

V. Phone/Fax

Practice location:
  • Phone: 228-255-8216
  • Fax: 228-255-8219
Mailing address:
  • Phone: 228-467-8600
  • Fax: 228-467-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR860556
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: