Basic Information
| Provider Information | |||||||||
| NPI: | 1154923704 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | LORRIAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 SHEPARD AVE | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076666157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016475943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4422 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189609000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 025430-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.