Provider Demographics
NPI:1902688138
Name:PORTER, BRAXTON
Entity Type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3338 W 1700 N
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9142
Mailing Address - Country:US
Mailing Address - Phone:801-866-4791
Mailing Address - Fax:
Practice Address - Street 1:448 N WERTH BLVD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7500
Practice Address - Country:US
Practice Address - Phone:503-554-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program