Provider Demographics
NPI:1396725792
Name:SPORER, KATHARINE C (NP-C)
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:C
Last Name:SPORER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E MANTUA AVE
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-1950
Mailing Address - Country:US
Mailing Address - Phone:856-468-6868
Mailing Address - Fax:856-464-1855
Practice Address - Street 1:107 E MANTUA AVE
Practice Address - Street 2:
Practice Address - City:WENONAH
Practice Address - State:NJ
Practice Address - Zip Code:08090-1950
Practice Address - Country:US
Practice Address - Phone:856-468-6868
Practice Address - Fax:856-464-1855
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO07781900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2793407Medicaid
NJS54908Medicare UPIN