Individual
MR. RYAN TODD PORTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
98 POPLAR ST, BLACKFOOT, ID 83221-1758
(208) 785-4100
Mailing address
98 POPLAR ST, BLACKFOOT, ID 83221-1758
(208) 785-4100
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
447
MT
363AS0400X
Surgical Physician Assistant
Primary
PA-827
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4307719
—
MT
05
—
808517600
—
ID
Enumeration date
10/24/2006
Last updated
12/30/2009
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