Provider Demographics
NPI:1811177231
Name:PORTER, JENNAE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNAE
Middle Name:MARIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59-016 HOLAWA ST
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712
Mailing Address - Country:US
Mailing Address - Phone:808-754-9037
Mailing Address - Fax:
Practice Address - Street 1:59-016 HOLAWA ST
Practice Address - Street 2:
Practice Address - City:HALEIWA
Practice Address - State:HI
Practice Address - Zip Code:96712
Practice Address - Country:US
Practice Address - Phone:808-754-9037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3739363AM0700X
HIAMD-1050363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2121337Medicare PIN