Provider Demographics
NPI:1154403319
Name:SANTIAGO, MAGDA E (PA)
Entity type:Individual
Prefix:
First Name:MAGDA
Middle Name:E
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 KAPPOCK ST
Mailing Address - Street 2:APT. 1K
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-7717
Mailing Address - Country:US
Mailing Address - Phone:718-792-8115
Mailing Address - Fax:718-792-2652
Practice Address - Street 1:MMC - EASTERN VASCULAR ASSOC.
Practice Address - Street 2:3219 EAST TREMONT AVENUE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-792-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant