Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0210X | Pediatric Nephrologist | 27617 | IA |
Y | 2080P0210X | Pediatric Nephrologist | 51603 | WI |
NPI | 1265413298 |
---|---|
Provider Name | Craig C Porter |
First Address | Milwaukee, WI 53226-4874 |
Second Address | Milwaukee, WI 53226-4874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2005 |
Last Update Date | 15/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0299891 | (05) | IA |
1265413298 | (05) | WI |
29989 | WELLMARK BCBS (01) | IA |
E39416 | (02) |