Provider Demographics
NPI:1972665982
Name:PORTA, CARISSA (NP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:PORTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 E GALBRAITH RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-6705
Mailing Address - Country:US
Mailing Address - Phone:513-686-4830
Mailing Address - Fax:513-686-4836
Practice Address - Street 1:4750 E GALBRAITH RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-6705
Practice Address - Country:US
Practice Address - Phone:513-686-4830
Practice Address - Fax:513-686-4836
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP09046363LA2200X
OH09046363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2727606Medicaid
OHNP22494Medicare PIN
OH2727606Medicaid