Healthcare Provider Details

I. General information

NPI: 1013457654
Provider Name (Legal Business Name): BRADLEY SCOTT PORTER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 FRANKLIN ST SUITE 205
BUFFALO NY
14202-2414
US

IV. Provider business mailing address

66 ORCHARD AVE UPPER APT
WEST SENECA NY
14224-1417
US

V. Phone/Fax

Practice location:
  • Phone: 716-856-2702
  • Fax: 716-856-8034
Mailing address:
  • Phone: 716-495-4149
  • Fax: 716-852-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number643069-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: