Provider Demographics
NPI:1295840593
Name:STA. ANA, ENRIQUE COLLANTES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:COLLANTES
Last Name:STA. ANA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:1100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8712
Practice Address - Country:US
Practice Address - Phone:304-757-8683
Practice Address - Fax:304-757-8684
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV11628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0056202000Medicaid
WV000416134OtherMSBCBS
WV550641245OtherFEIN
WV550641245OtherFEIN
WV000416134OtherMSBCBS
WV0453255Medicare PIN