Basic Information
| Provider Information | |||||||||
| NPI: | 1588898308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTA | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSCETTA | ||||||||
| OtherFirstName: | KENDRA | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BUSCETTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1102 A ST UNIT 1536 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532741668 | ||||||||
| FaxNumber: | 2532741685 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 A ST UNIT 1536 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532741668 | ||||||||
| FaxNumber: | 2532741685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 60389023 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | Q9006 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 359428502 | 05 | TX | MEDICAID | 8GC534 | 01 | TX | BCBS | OTHER | P01712915 | 01 | TX | RR | OTHER | 359428501 | 05 | TX | MEDICAID |