Basic Information
| Provider Information | |||||||||
| NPI: | 1023361649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTERFIELD | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONSTABLE | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1915 LENDEW ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362753325 | ||||||||
| FaxNumber: | 9197877247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 LENDEW ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362753325 | ||||||||
| FaxNumber: | 3362755346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2012 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0010-03861 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0010-03861 | 01 | NC | NC MEDICAL LICENSE | OTHER | PTAN9523A | 01 | NC | MEDICARE PTAN | OTHER | MC2747559 | 01 | NC | DEA | OTHER |