Provider Demographics
NPI:1093917213
Name:ALTMAN, LARISA (NP)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:ALTMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 CAREW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2377
Mailing Address - Country:US
Mailing Address - Phone:413-748-9349
Mailing Address - Fax:413-794-1629
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-9349
Practice Address - Fax:413-794-1629
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002903363LA2200X
MARN169231363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004029039Medicaid
MA110080335AMedicaid
CTD400002920 - C00814Medicare PIN