Provider Demographics
NPI:1659764041
Name:ALTAMIRANO, JOHN-MARIO WALTER (FNP)
Entity type:Individual
Prefix:
First Name:JOHN-MARIO
Middle Name:WALTER
Last Name:ALTAMIRANO
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5939
Mailing Address - Country:US
Mailing Address - Phone:337-988-1585
Mailing Address - Fax:337-981-4694
Practice Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5939
Practice Address - Country:US
Practice Address - Phone:337-988-1585
Practice Address - Fax:337-981-4694
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08184363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2387022Medicaid
LA410520YJQDMedicare PIN