MEDICARE: CARLOS DAMIAN SANTIAGO PA-C, DMO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9102280	FL

General Provider Information

NPI Number	:	1497718290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS DAMIAN SANTIAGO PA-C, DMO

Provider Business Mailing Address
First Line	:	1727 MARGARETS WALK RD
Second Line	:
City	:	GREEN COVE SPRINGS
State	:	FL
Zip	:	32043-3760
Country	:	US
Telephone Number	:	904-505-4040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1727 MARGARETS WALK RD
Second Line	:
City	:	GREEN COVE SPRINGS
State	:	FL
Zip	:	32043-3760
Country	:	US
Telephone Number	:	904-505-4040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	07/08/2007

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