Provider Demographics
NPI:1053403782
Name:PORTO MADURSKI, KRISTINE (PA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:PORTO MADURSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-428-4463
Mailing Address - Fax:619-428-2625
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2007
Practice Address - Country:US
Practice Address - Phone:619-428-4463
Practice Address - Fax:619-428-2625
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FHC18880FOtherMEDI CAL
FHC18880FOtherMEDI CAL
W5740Medicare ID - Type Unspecified