Provider Demographics
NPI:1235676792
Name:ANDERSON, DOUGLAS PORTER (PA)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:PORTER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:DOUGLAS
Other - Middle Name:PORTER
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:4637 WHITECHAPEL LN
Mailing Address - Street 2:
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-9780
Mailing Address - Country:US
Mailing Address - Phone:662-255-2163
Mailing Address - Fax:
Practice Address - Street 1:101 CUNNINGHAM DR
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1302
Practice Address - Country:US
Practice Address - Phone:662-837-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03482206Medicaid
559682YUY2Medicare Oscar/Certification