Provider Demographics
NPI:1821185851
Name:PORTER, CATHERINE J (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:J
Last Name:PORTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 DEERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-8076
Mailing Address - Country:US
Mailing Address - Phone:618-351-6619
Mailing Address - Fax:618-351-6619
Practice Address - Street 1:463 DEERFIELD LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-8076
Practice Address - Country:US
Practice Address - Phone:618-201-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00108404163WG0000X
IL041308103163WG0000X
MO067173163WG0000X, 367500000X
IL209000368367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205058Medicare ID - Type Unspecified