Healthcare Provider Details

I. General information

NPI: 1578875548
Provider Name (Legal Business Name): JOSHUA WILLIAM PORTER M.S., L.A.T., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MANNING WAY
UNIVERSITY MS
38677-1848
US

IV. Provider business mailing address

PO BOX 1848
UNIVERSITY MS
38677-1848
US

V. Phone/Fax

Practice location:
  • Phone: 662-915-7536
  • Fax: 662-915-5275
Mailing address:
  • Phone: 662-915-7536
  • Fax: 662-915-5275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0639
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: