Provider Demographics
NPI:1033390703
Name:PORTORREAL, ANGEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:PORTORREAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 SUMMERFIELD ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-8113
Mailing Address - Country:US
Mailing Address - Phone:718-795-7317
Mailing Address - Fax:
Practice Address - Street 1:1743 SUMMERFIELD ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-8113
Practice Address - Country:US
Practice Address - Phone:718-795-7317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2023-12-18
Deactivation Date:2023-11-27
Deactivation Code:
Reactivation Date:2023-12-18
Provider Licenses
StateLicense IDTaxonomies
NY226755-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888622Medicaid