MEDICARE: MS. JEAN ELIZABETH PORTER ANP

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	363LA2200X	Adult Health Nurse Practitioner	F301963	NY

General Provider Information

NPI Number	:	1942238308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN ELIZABETH PORTER ANP

Provider Business Mailing Address
First Line	:	21 KEELER DR
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12208-1926
Country	:	US
Telephone Number	:	518-458-2150
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PINE WEST PLZ
Second Line	:	WASHINGTON AVE EXT
City	:	ALBANY
State	:	NY
Zip	:	12205-5531
Country	:	US
Telephone Number	:	518-464-9999
Fax Number	:	518-464-9650

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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