Basic Information
| Provider Information | |||||||||
| NPI: | 1184894354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 DRINKWATER RD | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395201658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678600 | ||||||||
| FaxNumber: | 2284678674 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 B SHEPHERDS SQUARD | ||||||||
| Address2: | |||||||||
| City: | DIAMONDHEAD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282558216 | ||||||||
| FaxNumber: | 2282558219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 01/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R860556 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.