Healthcare Provider Details

I. General information

NPI: 1588212997
Provider Name (Legal Business Name): MICHAEL ROBERT PORCHERON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MEMORIAL DR STE C
JACKSONVILLE NC
28546-6328
US

IV. Provider business mailing address

PO BOX 986513 DEPARTMENT 100
BOSTON MA
02298-6513
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-9688
  • Fax: 910-353-7498
Mailing address:
  • Phone: 910-219-8326
  • Fax: 910-939-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5012401
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: