Provider Demographics
NPI:1497881742
Name:PORTER, PEGGY J (FNP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:J
Last Name:PORTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816587 MAMALAHOA HWY
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750
Mailing Address - Country:US
Mailing Address - Phone:808-323-3107
Mailing Address - Fax:808-323-0012
Practice Address - Street 1:81-6587 MAMALAHOA HWY
Practice Address - Street 2:C 201
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750
Practice Address - Country:US
Practice Address - Phone:808-323-3107
Practice Address - Fax:808-323-0012
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX440373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150022505Medicaid
TX150022506Medicaid
TX150022507Medicaid
TX150022505Medicaid
TXTXB123183Medicare PIN
TXTXB123185Medicare PIN
TXTXB123186Medicare PIN
TX150022507Medicaid
TXTXB114224Medicare PIN