Healthcare Provider Details

I. General information

NPI: 1477908184
Provider Name (Legal Business Name): MR. ANDREW E PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2016
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4975 FOOTE RD STE 400
MEDINA OH
44256-9048
US

IV. Provider business mailing address

2000 AUBURN DR STE 350
BEACHWOOD OH
44122-4327
US

V. Phone/Fax

Practice location:
  • Phone: 330-591-9038
  • Fax: 330-722-8585
Mailing address:
  • Phone: 440-646-1600
  • Fax: 440-646-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1135037
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number503004730RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: