Provider Demographics
NPI:1255309639
Name:PORCHE, CARLA D (CRNA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:D
Last Name:PORCHE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 465686
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30042-5686
Mailing Address - Country:US
Mailing Address - Phone:770-237-1561
Mailing Address - Fax:770-237-1124
Practice Address - Street 1:201 HOSPITAL RD
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2408
Practice Address - Country:US
Practice Address - Phone:404-851-6500
Practice Address - Fax:770-237-1124
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA134538367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR14810Medicare UPIN