Healthcare Provider Details

I. General information

NPI: 1649201161
Provider Name (Legal Business Name): TAMMIE JEAN PORRAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMMIE JEAN JOHNSON

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 LAKE ROAD AVE STE 301
ROBBINSDALE MN
55422-1845
US

IV. Provider business mailing address

4600 LAKE ROAD AVE STE 301
ROBBINSDALE MN
55422-1845
US

V. Phone/Fax

Practice location:
  • Phone: 763-588-7099
  • Fax: 763-522-2222
Mailing address:
  • Phone: 763-588-7099
  • Fax: 763-522-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR155408-9
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR155408-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: