Provider Demographics
NPI:1679247233
Name:ALTAMIRANO, MARISA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:RENEE
Last Name:ALTAMIRANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2042 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-6045
Mailing Address - Country:US
Mailing Address - Phone:858-205-9963
Mailing Address - Fax:
Practice Address - Street 1:2052 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-6028
Practice Address - Country:US
Practice Address - Phone:908-350-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant