Provider Demographics
NPI:1932143039
Name:PORTER, BONNIE D (CRNA)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:D
Last Name:PORTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 LILAC DR
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-4945
Mailing Address - Country:US
Mailing Address - Phone:620-624-4796
Mailing Address - Fax:
Practice Address - Street 1:15TH AT PERSHING
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-624-1651
Practice Address - Fax:620-629-6655
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54986207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS144662OtherBLUE CROSS
KS144662OtherBLUE CROSS
KS144662Medicare ID - Type Unspecified