Healthcare Provider Details

I. General information

NPI: 1063030146
Provider Name (Legal Business Name): MONICA PENON PORTMANN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 4TH ST FL 6
SAN FRANCISCO CA
94143-2350
US

IV. Provider business mailing address

PO BOX 5371
SEATTLE WA
98145-5005
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-2757
  • Fax:
Mailing address:
  • Phone: 206-987-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61396866
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA202566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: