Provider Demographics
NPI:1609240175
Name:PENA, SANTIAGO (PA-C)
Entity Type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:PENA
Suffix:
Gender:M
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 1:5673 CORAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3124
Mailing Address - Country:US
Mailing Address - Phone:954-837-1481
Mailing Address - Fax:
Practice Address - Street 1:5673 CORAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3124
Practice Address - Country:US
Practice Address - Phone:954-837-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-21
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant