Provider Demographics
NPI:1407024383
Name:PORTAN, LIDIA
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:PORTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6559 W PINNACLE PEAK RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3415
Mailing Address - Country:US
Mailing Address - Phone:623-376-6134
Mailing Address - Fax:
Practice Address - Street 1:6559 W PINNACLE PEAK RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3415
Practice Address - Country:US
Practice Address - Phone:623-376-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-6526171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZALH-6526OtherAZ DHS