Provider Demographics
NPI:1104935303
Name:PORTO, JENNIFER MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:PORTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741331
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1331
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:913-469-5267
Practice Address - Street 1:10600 MASTIN ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-5723
Practice Address - Country:US
Practice Address - Phone:913-469-6447
Practice Address - Fax:913-338-1311
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006022546363A00000X
KST00749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant