Provider Demographics
NPI:1508407529
Name:SANTIAGO, MARIO (PA)
Entity Type:Individual
Prefix:
First Name:MARIO
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 1:141 W 74TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2258
Mailing Address - Country:US
Mailing Address - Phone:786-877-1775
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant