NPI |
1609831809 |
The other abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Entity Type Code |
1 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Last Name Legal Name |
PORRAS |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider First Name |
MARIO |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
Provider Middle Name |
E |
The city name in the location address of the provider being identified. |
Provider Credential Text |
M.D. |
The State code in the location of the provider
being identified. |
Provider First Line Business Practice Location Address |
80 N MAIN ST |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address City Name |
COUPEVILLE |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
WA |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
982399500 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Business Practice Location Address Country Code If outside U S |
US |
The date that a record was last updated or changed. |
Provider Business Practice Location Address Telephone Number |
3606784424 |
The code designating the provider’s gender if the provider is a person. |
Provider Business Practice Location Address Fax Number |
3606785161 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Enumeration Date |
4/19/2006 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Last Update Date |
8/31/2017 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Gender Code |
M |
|
Healthcare Provider Taxonomy Code 1 |
207X00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
MD60318075 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
WA |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Healthcare Provider Taxonomy Code 2 |
207X00000X |
|
Provider License Number 2 |
TP027 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 2 |
KY |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 2 |
N |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |