Provider Demographics
NPI:1639237407
Name:PORRAS, OPAL K (APRN, CWON-AP, CCCN)
Entity Type:Individual
Prefix:MRS
First Name:OPAL
Middle Name:K
Last Name:PORRAS
Suffix:
Gender:F
Credentials:APRN, CWON-AP, CCCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MACARTHUR BLVD
Mailing Address - Street 2:WOUND OSTOMY CLINIC
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2901
Mailing Address - Country:US
Mailing Address - Phone:219-838-1757
Mailing Address - Fax:219-836-7058
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:WOULD OSTOMY CLINIC
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-836-7713
Practice Address - Fax:219-836-7058
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000151A364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941410QQQQMedicare PIN