Healthcare Provider Details

I. General information

NPI: 1255970992
Provider Name (Legal Business Name): CLINT JAMES SANTIAGO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2019
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E DIXIE AVE
LEESBURG FL
34748-5925
US

IV. Provider business mailing address

1329 SW 16TH ST RM 2232
GAINESVILLE FL
32608-1128
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-5762
  • Fax:
Mailing address:
  • Phone: 352-559-5051
  • Fax: 352-265-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11013006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: