Provider Demographics
NPI:1679679880
Name:PORRAS, ENRIQUETA M (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUETA
Middle Name:M
Last Name:PORRAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4213
Mailing Address - Country:US
Mailing Address - Phone:602-234-9611
Mailing Address - Fax:602-234-0011
Practice Address - Street 1:600 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4213
Practice Address - Country:US
Practice Address - Phone:602-234-9611
Practice Address - Fax:602-234-0011
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ894370Medicaid
AZ894370Medicaid