MEDICARE: MR. JOSHUA WILLIAM PORTER M.S., L.A.T., A.T.C.

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	2255A2300X	Athletic Trainer	0639	MS

General Provider Information

NPI Number	:	1578875548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSHUA WILLIAM PORTER M.S., L.A.T., A.T.C.

Provider Business Mailing Address
First Line	:	PO BOX 1848
Second Line	:
City	:	UNIVERSITY
State	:	MS
Zip	:	38677-1848
Country	:	US
Telephone Number	:	662-915-7536
Fax Number	:	662-915-5275

Provider Business Practice Location Address
First Line	:	1810 MANNING WAY
Second Line	:
City	:	UNIVERSITY
State	:	MS
Zip	:	38677-1848
Country	:	US
Telephone Number	:	662-915-7536
Fax Number	:	662-915-5275

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

Provider Enumeration Date	:	07/07/2010
Last Update Date	:	12/03/2014

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