Provider Demographics
NPI:1720039183
Name:LATTIMORE, VIVA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VIVA
Middle Name:A
Last Name:LATTIMORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VIVA
Other - Middle Name:A
Other - Last Name:AGGARWAL/APOLLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:205 SOUTH FRONT STREET
Mailing Address - Street 2:4TH FLOOR, BMA
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104
Mailing Address - Country:US
Mailing Address - Phone:717-231-8555
Mailing Address - Fax:717-231-8568
Practice Address - Street 1:205 SOUTH FRONT STREET
Practice Address - Street 2:4TH FLOOR, BMA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-231-8555
Practice Address - Fax:717-231-8568
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003300L363AM0700X
PAMA00300L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP08174Medicare UPIN
PA088007TWMMedicare PIN
PA038487Medicare ID - Type Unspecified