Provider Demographics
NPI:1760120422
Name:BATES, PORSHA
Entity Type:Individual
Prefix:
First Name:PORSHA
Middle Name:
Last Name:BATES
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 1:4054 N 69TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1121
Mailing Address - Country:US
Mailing Address - Phone:262-893-2451
Mailing Address - Fax:
Practice Address - Street 1:4054 N 69TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1121
Practice Address - Country:US
Practice Address - Phone:262-893-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver