Basic Information
| Provider Information | |||||||||
| NPI: | 1437197647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3544 E 17TH ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | AMMON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834066910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085222922 | ||||||||
| FaxNumber: | 2085226330 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 HOSPITAL WAY | ||||||||
| Address2: | SUITE 801 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006134012 | ||||||||
| FaxNumber: | 2082333416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | NP376A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.