Provider Demographics
NPI:1053390450
Name:PORTER, GREGORY (PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-2003
Mailing Address - Country:US
Mailing Address - Phone:304-768-8500
Mailing Address - Fax:304-720-8722
Practice Address - Street 1:707 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2003
Practice Address - Country:US
Practice Address - Phone:304-768-8500
Practice Address - Fax:304-768-8530
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00672363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001718067OtherWV BCBS
OH3000325OtherOH BWC
OH3000325OtherOH BWC
WVP24462Medicare UPIN
WV001718067OtherWV BCBS
WVPOPA16523Medicare PIN
WVP00001449Medicare PIN
WVP00001450Medicare PIN
WVPOPA16522Medicare PIN