Provider Demographics
NPI:1538867148
Name:PORTER, PAULA ANNE
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:ANNE
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WALMART DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-8692
Mailing Address - Country:US
Mailing Address - Phone:740-288-2718
Mailing Address - Fax:740-288-2720
Practice Address - Street 1:100 WALMART DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-8692
Practice Address - Country:US
Practice Address - Phone:740-288-2718
Practice Address - Fax:740-288-2720
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.016887-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician