Healthcare Provider Details

I. General information

NPI: 1770526303
Provider Name (Legal Business Name): LUIS SANTIAGO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3ACR BLDG 1650, BARKLEY AVE
FT. CARSON CO
80913
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-6699
  • Fax:
Mailing address:
  • Phone: 970-624-4036
  • Fax: 970-490-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0002445
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: