Healthcare Provider Details

I. General information

NPI: 1932159159
Provider Name (Legal Business Name): NANCY ALTAMIRANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANCY FAJARDO MCQUILKIN MD

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WOODLAND DR
COOS BAY OR
97420-2099
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-2099
US

V. Phone/Fax

Practice location:
  • Phone: 541-267-5151
  • Fax: 541-266-4566
Mailing address:
  • Phone: 541-267-5151
  • Fax: 541-266-4566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101056004
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD190330
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierC09463
Identifier TypeOTHER
Identifier StateVA
Identifier IssuerGROUP PTAN
# 2
Identifier500759702
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: