Provider Demographics
NPI:1114799327
Name:MAYO PORTER, CORTREANA (PDW)
Entity Type:Individual
Prefix:
First Name:CORTREANA
Middle Name:
Last Name:MAYO PORTER
Suffix:
Gender:F
Credentials:PDW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 41ST ST NE APT 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-3325
Mailing Address - Country:US
Mailing Address - Phone:202-909-5964
Mailing Address - Fax:
Practice Address - Street 1:101 41ST ST NE APT 101
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3325
Practice Address - Country:US
Practice Address - Phone:202-909-5964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other