Provider Demographics
NPI:1881633485
Name:PORTER-PURSNANI, CARLA JEAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:JEAN
Last Name:PORTER-PURSNANI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:CARLA
Other - Middle Name:JEAN
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:4108 ADMIRALTY LN
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1678
Mailing Address - Country:US
Mailing Address - Phone:650-477-1891
Mailing Address - Fax:
Practice Address - Street 1:4108 ADMIRALTY LN
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1678
Practice Address - Country:US
Practice Address - Phone:650-477-1891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005679213E00000X, 213ER0200X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355931Medicaid
NY02275712Medicaid
PG809PAE21Medicare PIN
NY00355931Medicaid
NYU89365Medicare UPIN