Provider Demographics
NPI:1457879488
Name:ALTAMIMI, LAITH MOHAMMAD ALI (NP)
Entity Type:Individual
Prefix:
First Name:LAITH
Middle Name:MOHAMMAD ALI
Last Name:ALTAMIMI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:LAITH ALTAMIMI
Other - Middle Name:
Other - Last Name:NURSE PRACTITIONER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 7058
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93290-7058
Mailing Address - Country:US
Mailing Address - Phone:559-622-0100
Mailing Address - Fax:559-622-0700
Practice Address - Street 1:5345 W HILLSDALE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5143
Practice Address - Country:US
Practice Address - Phone:596-220-1005
Practice Address - Fax:559-622-0700
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010887363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95010887OtherNP