Provider Demographics
NPI:1366481178
Name:PORTER, PAMELA SUE (APRN, MSN, FNP,BC)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:SUE
Last Name:PORTER
Suffix:
Gender:F
Credentials:APRN, MSN, FNP,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 LAGUNA AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4918
Mailing Address - Country:US
Mailing Address - Phone:916-923-2107
Mailing Address - Fax:916-648-9131
Practice Address - Street 1:9281 OFFICE PARK CIR
Practice Address - Street 2:SUITE 120
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8068
Practice Address - Country:US
Practice Address - Phone:916-691-5988
Practice Address - Fax:916-691-6717
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 445209 FNP 6259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS18205Medicare UPIN