Healthcare Provider Details

I. General information

NPI: 1659025385
Provider Name (Legal Business Name): LINDSEY PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RINGNECK RD
PERALTA NM
87042-8439
US

IV. Provider business mailing address

3 RINGNECK RD
PERALTA NM
87042-8439
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-4870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0127
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: