Provider Demographics
NPI:1013431212
Name:ALTAMIRANO, GABRIEL LEYBA (ACNPC-AG)
Entity type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:LEYBA
Last Name:ALTAMIRANO
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S PANTANO RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4132
Mailing Address - Country:US
Mailing Address - Phone:520-465-5990
Mailing Address - Fax:
Practice Address - Street 1:2450 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6526
Practice Address - Country:US
Practice Address - Phone:520-795-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10441363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care