Healthcare Provider Details

I. General information

NPI: 1518880350
Provider Name (Legal Business Name): SANTIAGO SIERRA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 VAN NUYS BLVD
SHERMAN OAKS CA
91403-1702
US

IV. Provider business mailing address

4929 VAN NUYS BLVD ATTN:CREDENTIALING/MEDICAL STAFF OFFICE
SHERMAN OAKS CA
91403-1702
US

V. Phone/Fax

Practice location:
  • Phone: 818-907-4570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: