Healthcare Provider Details

I. General information

NPI: 1396042933
Provider Name (Legal Business Name): KURT PORTER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8393 CHERRY BLOSSOM DR
WINDSOR CO
80550-8042
US

IV. Provider business mailing address

8393 CHERRY BLOSSOM DR
WINDSOR CO
80550-8042
US

V. Phone/Fax

Practice location:
  • Phone: 301-580-3768
  • Fax:
Mailing address:
  • Phone: 301-580-3768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0992576-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: