Healthcare Provider Details

I. General information

NPI: 1053019018
Provider Name (Legal Business Name): ANN MARIE PORTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N 162ND AVE STE 300
OMAHA NE
68118-2540
US

IV. Provider business mailing address

515 N 162ND AVE STE 300
OMAHA NE
68118-2540
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-1200
  • Fax: 402-354-1205
Mailing address:
  • Phone: 402-354-1200
  • Fax: 402-354-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: