Provider Demographics
NPI:1528368065
Name:PORTENIER, THEA
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:PORTENIER
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 1:1803 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66968-8704
Mailing Address - Country:US
Mailing Address - Phone:785-325-2787
Mailing Address - Fax:
Practice Address - Street 1:1803 WILSON ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:KS
Practice Address - Zip Code:66968
Practice Address - Country:US
Practice Address - Phone:785-541-0385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100394380BMedicaid