MEDICARE: MRS. CATHERINE J PORTER CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	RN00108404	WA
2	163WG0000X	General Practice Registered Nurse	041308103	IL
3	163WG0000X	General Practice Registered Nurse	067173	MO
4	367500000X	Certified Registered Nurse Anesthetist	067173	MO
5	367500000X	Certified Registered Nurse Anesthetist	209000368	IL

General Provider Information

NPI Number	:	1821185851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CATHERINE J PORTER CRNA

Provider Business Mailing Address
First Line	:	463 DEERFIELD LN
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62902-8076
Country	:	US
Telephone Number	:	618-351-6619
Fax Number	:	618-351-6619

Provider Business Practice Location Address
First Line	:	463 DEERFIELD LN
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62902-8076
Country	:	US
Telephone Number	:	618-201-2240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	10/08/2018

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