Provider Demographics
NPI:1013738517
Name:SAN MIGUEL, ELISA ROSEANN
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:ROSEANN
Last Name:SAN MIGUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 W GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3723
Mailing Address - Country:US
Mailing Address - Phone:989-401-7588
Mailing Address - Fax:
Practice Address - Street 1:2720 W GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3723
Practice Address - Country:US
Practice Address - Phone:989-401-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist