Healthcare Provider Details

I. General information

NPI: 1801629662
Provider Name (Legal Business Name): JAIME SANTIESTEBAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 N TELSHOR BLVD
LAS CRUCES NM
88011-8202
US

IV. Provider business mailing address

7121 WESTOVER DR
EL PASO TX
79912-7681
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-7890
  • Fax:
Mailing address:
  • Phone: 915-258-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010197
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: