Provider Demographics
NPI:1508261686
Name:ALTAVAS, MAE CARMELA
Entity Type:Individual
Prefix:
First Name:MAE CARMELA
Middle Name:
Last Name:ALTAVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8016 KENTSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3927
Mailing Address - Country:US
Mailing Address - Phone:702-277-7717
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-2661
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001453363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner