Provider Demographics
NPI:1104303569
Name:SANTANA, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SANTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 W 139TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1508
Mailing Address - Country:US
Mailing Address - Phone:212-632-4532
Mailing Address - Fax:
Practice Address - Street 1:34 W 139TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1508
Practice Address - Country:US
Practice Address - Phone:212-632-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY656554545OtherNEW YORK STATE LEARNER PERMIT
NY88362293689Medicaid