Healthcare Provider Details

I. General information

NPI: 1689224073
Provider Name (Legal Business Name): MARGO ILIMA SANTIAGO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone: 505-368-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2019-0065
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2019-0065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: