Healthcare Provider Details

I. General information

NPI: 1922079607
Provider Name (Legal Business Name): JAMES AUSTIN PORTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 BRAEBURN DR SUITE M120
SALEM VA
24153-7357
US

IV. Provider business mailing address

1802 BRAEBURN DR SUITE M120
SALEM VA
24153-7357
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-3668
  • Fax: 540-774-4615
Mailing address:
  • Phone: 540-344-3668
  • Fax: 540-774-4615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110840594
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110840594
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: