Provider Demographics
NPI:1669047163
Name:SAN JUAN, JESSE ANGELICA QUITALIG (MD)
Entity type:Individual
Prefix:MS
First Name:JESSE ANGELICA
Middle Name:QUITALIG
Last Name:SAN JUAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 ALBERTA AVENUE
Mailing Address - Street 2:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER, DEPARTMEN
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1298
Mailing Address - Country:US
Mailing Address - Phone:915-215-5557
Mailing Address - Fax:915-545-6442
Practice Address - Street 1:4800 ALBERTA AVENUE
Practice Address - Street 2:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER, DEPARTMEN
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-1298
Practice Address - Country:US
Practice Address - Phone:915-215-5557
Practice Address - Fax:915-545-6442
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2023-04-29
Deactivation Date:2022-11-23
Deactivation Code:
Reactivation Date:2023-02-23
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator