Provider Demographics
NPI:1205598463
Name:ALTIDOR, SABINE
Entity type:Individual
Prefix:
First Name:SABINE
Middle Name:
Last Name:ALTIDOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S WILLAMAN DR APT 106
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-3944
Mailing Address - Country:US
Mailing Address - Phone:678-591-0342
Mailing Address - Fax:
Practice Address - Street 1:425 S WILLAMAN DR APT 106
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3944
Practice Address - Country:US
Practice Address - Phone:678-591-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAG06210112363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology