Provider Demographics
NPI:1417482282
Name:PORTER, CHRISTINE KAY (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:KAY
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1825
Mailing Address - Country:US
Mailing Address - Phone:303-449-0933
Mailing Address - Fax:
Practice Address - Street 1:3575 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1825
Practice Address - Country:US
Practice Address - Phone:303-449-0933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
COPA.0005099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant