Provider Demographics
NPI:1609831809
Name:PORRAS, MARIO E (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:E
Last Name:PORRAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 770
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-0770
Mailing Address - Country:US
Mailing Address - Phone:360-678-4424
Mailing Address - Fax:360-678-5161
Practice Address - Street 1:80 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-9500
Practice Address - Country:US
Practice Address - Phone:360-678-4424
Practice Address - Fax:360-678-5161
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60318075207X00000X
KYTP027207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8862175Medicare PIN
NVC96457Medicare UPIN