Basic Information
| Provider Information | |||||||||
| NPI: | 1184067993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JANELLE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 BLAZIER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123598900 | ||||||||
| FaxNumber: | 4123598977 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 BLAZIER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123598900 | ||||||||
| FaxNumber: | 4123598977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5378 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | C05615 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | MA062766 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103682874 | 05 | PA | MEDICAID | 12565703 | 01 | CAQH | OTHER |