Provider Demographics
NPI:1649201161
Name:PORRAS, TAMMIE JEAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:TAMMIE
Middle Name:JEAN
Last Name:PORRAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:JEAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4600 LAKE ROAD AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1845
Mailing Address - Country:US
Mailing Address - Phone:763-588-7099
Mailing Address - Fax:763-522-2222
Practice Address - Street 1:4600 LAKE ROAD AVE STE 301
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-1845
Practice Address - Country:US
Practice Address - Phone:763-588-7099
Practice Address - Fax:763-522-2222
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR155408-9363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1508102500OtherGROUP NPI
MNCO9271OtherGROUP MEDICARE