Healthcare Provider Details

I. General information

NPI: 1437925336
Provider Name (Legal Business Name): TYLER SHAWN PORTER PT, DPT, MED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MADISON ST STE LL2
ALEXANDRIA VA
22314-2065
US

IV. Provider business mailing address

163 CARDOVA DR
MAX MEADOWS VA
24360-3651
US

V. Phone/Fax

Practice location:
  • Phone: 703-299-6688
  • Fax:
Mailing address:
  • Phone: 276-620-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP22776
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP038518T
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305216214
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: