Healthcare Provider Details

I. General information

NPI: 1316375744
Provider Name (Legal Business Name): PEDRO PORTES ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S BLDG 25
ORANGE CA
92868-3201
US

IV. Provider business mailing address

200 S MANCHESTER AVE STE 300
ORANGE CA
92868-3219
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6699
  • Fax:
Mailing address:
  • Phone: 714-456-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number23628
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number23628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: