Healthcare Provider Details

I. General information

NPI: 1285206136
Provider Name (Legal Business Name): SAMANTHA NICOLE ALTAMIRANO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA NICOLE MCTEE ATC

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1149 DESOTO AVE
YPSILANTI MI
48198-6279
US

V. Phone/Fax

Practice location:
  • Phone: 509-307-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005906
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number60865271
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: