Provider Demographics
NPI:1043879505
Name:PAGAN, MIGUEL DAMIAN SR
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:DAMIAN
Last Name:PAGAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 4 BOX 43527
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-9420
Mailing Address - Country:US
Mailing Address - Phone:787-517-0489
Mailing Address - Fax:
Practice Address - Street 1:55 CALLE PALMA
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4526
Practice Address - Country:US
Practice Address - Phone:787-517-0489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR115461367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR115461Medicaid