Provider Demographics
NPI:1427886076
Name:ALONZO SANTIAGO, MIA MILENA (PA)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MILENA
Last Name:ALONZO 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 1:1200 DELTONA BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-6306
Mailing Address - Country:US
Mailing Address - Phone:386-742-1766
Mailing Address - Fax:
Practice Address - Street 1:1220 SOUTHERLY PARC LN APT 102
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8100
Practice Address - Country:US
Practice Address - Phone:787-310-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant