Provider Demographics
NPI:1912302969
Name:ALTAMIRANO, GUSTAVO
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:ALTAMIRANO
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 1:395 JUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-1130
Mailing Address - Country:US
Mailing Address - Phone:415-577-4052
Mailing Address - Fax:
Practice Address - Street 1:395 JUSTIN DR
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-1130
Practice Address - Country:US
Practice Address - Phone:415-577-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00708599376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide