Provider Demographics
NPI:1083241137
Name:SANTIAGO, JOSE F
Entity Type:Individual
Prefix:
First Name:JOSE F
Middle Name:
Last Name:SANTIAGO
Suffix:
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 1:13625 FM 2769
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-2602
Mailing Address - Country:US
Mailing Address - Phone:512-496-6034
Mailing Address - Fax:
Practice Address - Street 1:2624 W WILLIAM CANNON DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5251
Practice Address - Country:US
Practice Address - Phone:512-496-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX08161882OtherDIRECT SERVICE TO PATIENT UNDER HHS CUSTODY