Provider Demographics
NPI:1215044672
Name:SANTIAGO, JESUS (PA)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5203
Mailing Address - Country:US
Mailing Address - Phone:203-661-3333
Mailing Address - Fax:203-661-5610
Practice Address - Street 1:25 VALLEY DR
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5203
Practice Address - Country:US
Practice Address - Phone:203-661-3333
Practice Address - Fax:203-661-5610
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970000974Medicare ID - Type Unspecified