Healthcare Provider Details

I. General information

NPI: 1861313561
Provider Name (Legal Business Name): KOLE PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2771 N GAREY AVE UNIT 136
POMONA CA
91767-1877
US

IV. Provider business mailing address

2771 N GAREY AVE UNIT 136
POMONA CA
91767-1877
US

V. Phone/Fax

Practice location:
  • Phone: 925-446-9832
  • Fax:
Mailing address:
  • Phone: 925-446-9832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number95040688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: