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General NPI Number Information
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NPI Number | 1497449847
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Entity Type | Individual
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Provider Name | JASON PORTER DO
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Gender | Male
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Dates
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Enumeration Date | 06/07/2023
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Last Update Date | 06/07/2023
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Provider Practice Location Address
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Address Line | 3269 N STOCKTON HILL RD
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City | KINGMAN
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State | AZ
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Zip | 86409-3619
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Country | US
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Telephone | 928-681-8701
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Fax |
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Provider Business Mailing Address
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Address Line | 1840 W ARROW RTE APT 98
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City | UPLAND
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State | CA
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Zip | 91786-7669
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Country | US
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Telephone | 909-630-1980
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | R4140
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License Number State | CA
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