Provider Demographics
NPI:1770162794
Name:LATTA, PUSHPA (FNP)
Entity type:Individual
Prefix:MRS
First Name:PUSHPA
Middle Name:
Last Name:LATTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-2534
Mailing Address - Country:US
Mailing Address - Phone:530-458-8635
Mailing Address - Fax:
Practice Address - Street 1:555 FREMONT ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2534
Practice Address - Country:US
Practice Address - Phone:530-458-8635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017065363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty