Provider Demographics
NPI:1699162164
Name:PORTER, TARA N (LMP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:N
Last Name:PORTER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SOUTH 336TH STREET STE C
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-391-7216
Mailing Address - Fax:
Practice Address - Street 1:530 S 336TH ST STE C
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6383
Practice Address - Country:US
Practice Address - Phone:253-391-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60101618174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911990894OtherITIN