Provider Demographics
NPI:1649762352
Name:SANTOS, JOHN ALEXANDER (APN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALEXANDER
Last Name:SANTOS
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 E STATE ST STE 209
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-1572
Mailing Address - Country:US
Mailing Address - Phone:815-988-8500
Mailing Address - Fax:815-977-5956
Practice Address - Street 1:2222 E STATE ST STE 209
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1572
Practice Address - Country:US
Practice Address - Phone:815-988-8500
Practice Address - Fax:815-977-5956
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily