Provider Demographics
NPI:1982248761
Name:SANTIAGO, JAYSON GERONIMO
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:GERONIMO
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 TOSCANA DR
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1470
Mailing Address - Country:US
Mailing Address - Phone:707-334-9839
Mailing Address - Fax:
Practice Address - Street 1:30 MARK WEST SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1436
Practice Address - Country:US
Practice Address - Phone:707-334-9839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012332363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care