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General NPI Number Information
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NPI Number | 1982410049
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Entity Type | Individual
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Provider Name | JONATHON THOMAS PORTARO NP
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Gender | Male
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 02/28/2025
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Provider Practice Location Address
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Address Line | 10201 E JEFFERSON AVE
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City | DETROIT
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State | MI
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Zip | 48214-3149
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Country | US
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Telephone | 888-813-8326
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Fax |
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Provider Business Mailing Address
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Address Line | 10201 E JEFFERSON AVE
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City | DETROIT
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State | MI
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Zip | 48214
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Country | US
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Telephone | 313-396-5300
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Fax | 313-274-4900
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 4704330807
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License Number State | MI
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