Provider Demographics
NPI:1639785876
Name:SANTOS, CARLOS E JR (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:E
Last Name:SANTOS
Suffix:JR
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:6033 E PRADO ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3938
Mailing Address - Country:US
Mailing Address - Phone:909-762-6072
Mailing Address - Fax:
Practice Address - Street 1:31700 TEMECULA PKWY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5896
Practice Address - Country:US
Practice Address - Phone:951-331-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2020008511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2020008511Medicaid