Provider Demographics
NPI:1326695792
Name:SANTIAGO, HEIDI MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MICHELLE
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:MICHELLE
Other - Last Name:WALBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 POST RD W
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4703
Mailing Address - Country:US
Mailing Address - Phone:203-332-3272
Mailing Address - Fax:
Practice Address - Street 1:300 POST RD W
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4703
Practice Address - Country:US
Practice Address - Phone:203-332-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT4630363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4630OtherSTATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH