Healthcare Provider Details

I. General information

NPI: 1952941031
Provider Name (Legal Business Name): JONATHON PETER PORTINCASA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

120 QUAIL RUN
PINEHURST NC
28374-9096
US

IV. Provider business mailing address

120 QUAIL RUN
PINEHURST NC
28374-9096
US

V. Phone/Fax

Practice location:
  • Phone: 231-736-6541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number006290
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024186941
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number331814
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: