Basic Information
| Provider Information | |||||||||
| NPI: | 1104587419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORFILIO-STITT | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1617 PALMETTO PALM DR | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295797088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434579151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 809 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2022 | ||||||||
| LastUpdateDate: | 01/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MPA.4246 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.