Provider Demographics
NPI:1265248561
Name:ALTAN, MIKHAIL
Entity type:Individual
Prefix:MR
First Name:MIKHAIL
Middle Name:
Last Name:ALTAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3841
Mailing Address - Country:US
Mailing Address - Phone:203-610-1148
Mailing Address - Fax:
Practice Address - Street 1:17 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-3841
Practice Address - Country:US
Practice Address - Phone:203-610-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily