Healthcare Provider Details

I. General information

NPI: 1467414474
Provider Name (Legal Business Name): RAYMOND SANTIAGO P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 OFFICE PARK DR
PALM COAST FL
32137-3808
US

IV. Provider business mailing address

6 OFFICE PARK DR
PALM COAST FL
32137-3808
US

V. Phone/Fax

Practice location:
  • Phone: 386-447-6615
  • Fax: 386-447-1266
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA3601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: