Provider Demographics
NPI:1588898308
Name:PORTA, KENDRA JO (MD)
Entity type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:JO
Last Name:PORTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:JO
Other - Last Name:BUSCETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BUSCETTA
Mailing Address - Street 1:1102 A ST UNIT 1536
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1210
Mailing Address - Country:US
Mailing Address - Phone:253-274-1668
Mailing Address - Fax:253-274-1685
Practice Address - Street 1:1102 A ST UNIT 1536
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98401-1210
Practice Address - Country:US
Practice Address - Phone:253-274-1668
Practice Address - Fax:253-274-1685
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60389023207L00000X
TXQ9006207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX359428502Medicaid
TX8GC534OtherBCBS
TXP01712915OtherRR
TX359428501Medicaid
TX359428501Medicaid