Provider Demographics
NPI:1679914071
Name:HUSSAIN, MOHAMED ALTAF (APRN)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:ALTAF
Last Name:HUSSAIN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 UNION ST
Mailing Address - Street 2:
Mailing Address - City:VERNON ROCKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3025
Mailing Address - Country:US
Mailing Address - Phone:860-375-8440
Mailing Address - Fax:860-858-4091
Practice Address - Street 1:145 UNION STREET
Practice Address - Street 2:
Practice Address - City:VERNON ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-3025
Practice Address - Country:US
Practice Address - Phone:860-375-8440
Practice Address - Fax:860-858-4091
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5393363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008045576Medicaid
CT008064264Medicaid