Healthcare Provider Details

I. General information

NPI: 1699876862
Provider Name (Legal Business Name): ALFREDO ALTAMIRANO P.A. - C, MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/21/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 MN-79
ELBOW LAKE MN
56531
US

IV. Provider business mailing address

4275 N RILLITO CREEK PL
TUCSON AZ
85719-1164
US

V. Phone/Fax

Practice location:
  • Phone: 218-685-7300
  • Fax:
Mailing address:
  • Phone: 520-548-1150
  • Fax: 520-795-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2632
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10572
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: