=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134783368
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MESIAH O'MAR PORTER JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2019
-----------------------------------------------------
Last Update Date | 04/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 SATELLITE BLVD STE 3
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-614-6266
-----------------------------------------------------
Fax | 770-623-9949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3085 BENTWOOD DR
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31503-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-288-1024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 83-1469962
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------