1104874577 NPI number — NINA MARIE ALTMAN MED BSPT

Table of content: NINA MARIE ALTMAN MED BSPT (NPI 1104874577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104874577 NPI number — NINA MARIE ALTMAN MED BSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALTMAN
Provider First Name:
NINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MED BSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HATTON OR HENDERSON
Provider Other First Name:
NINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104874577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4040 ORCHARD ST W
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FIRCREST
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98466-6606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-564-1560
Provider Business Mailing Address Fax Number:
253-564-4449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7308 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-8000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-582-8500
Provider Business Practice Location Address Fax Number:
253-582-8506
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00002421 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8363830 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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