Healthcare Provider Details

I. General information

NPI: 1497718290
Provider Name (Legal Business Name): CARLOS DAMIAN SANTIAGO PA-C, DMO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 MARGARETS WALK RD
GREEN COVE SPRINGS FL
32043-3760
US

IV. Provider business mailing address

1727 MARGARETS WALK RD
GREEN COVE SPRINGS FL
32043-3760
US

V. Phone/Fax

Practice location:
  • Phone: 904-505-4040
  • Fax:
Mailing address:
  • Phone: 904-505-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9102280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: