Provider Demographics
NPI:1497218028
Name:SANT ANTONIO, ANGELICA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:SANT ANTONIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21110 BISCAYNE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1252
Mailing Address - Country:US
Mailing Address - Phone:305-918-7050
Mailing Address - Fax:305-918-7051
Practice Address - Street 1:21110 BISCAYNE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1252
Practice Address - Country:US
Practice Address - Phone:305-918-7050
Practice Address - Fax:305-918-7051
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9113606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program