Provider Demographics
NPI:1255863890
Name:FRAGOSO SANTANA, ANDREA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:FRAGOSO SANTANA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 LAS PALMAS CIR APT 712
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2882
Mailing Address - Country:US
Mailing Address - Phone:956-592-9875
Mailing Address - Fax:
Practice Address - Street 1:1201 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3831
Practice Address - Country:US
Practice Address - Phone:956-542-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-02
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant