Healthcare Provider Details

I. General information

NPI: 1114799327
Provider Name (Legal Business Name): CORTREANA MAYO PORTER PDW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 41ST ST NE APT 101
WASHINGTON DC
20019-3325
US

IV. Provider business mailing address

101 41ST ST NE APT 101
WASHINGTON DC
20019-3325
US

V. Phone/Fax

Practice location:
  • Phone: 202-909-5964
  • Fax:
Mailing address:
  • Phone: 202-909-5964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: