Provider Demographics
NPI:1356829931
Name:SANTOS, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SANTOS
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 1:9245 REGENTS RD UNIT M109
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9245 REGENTS RD UNIT M109
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9264
Practice Address - Country:US
Practice Address - Phone:619-301-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist