MEDICARE: DOUGLAS ASHLEY PORTER M-PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1477863322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS ASHLEY PORTER M-PAC

Provider Business Mailing Address
First Line	:	3110 LYLEWOOD RD
Second Line	:
City	:	WOODLAWN
State	:	TN
Zip	:	37191-8232
Country	:	US
Telephone Number	:	931-542-6193
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 LYLEWOOD RD
Second Line	:
City	:	WOODLAWN
State	:	TN
Zip	:	37191-8232
Country	:	US
Telephone Number	:	931-542-6193
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2010
Last Update Date	:	10/13/2010

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