Provider Demographics
NPI:1922406222
Name:ESCOBAR ACEVEDO, LUIS SANTIAGO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:SANTIAGO
Last Name:ESCOBAR ACEVEDO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:LUIS
Other - Middle Name:SANTIAGO
Other - Last Name:ESCOBAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1101 MOULTON AND PARSONS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-5550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6460
Practice Address - Country:US
Practice Address - Phone:507-625-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant