Provider Demographics
NPI:1376377622
Name:PETALVER, SANTIAGO (BSN, RN, MBA)
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:PETALVER
Suffix:
Gender:M
Credentials:BSN, RN, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 68TH ST.
Mailing Address - Street 2:6B
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:917-215-6372
Mailing Address - Fax:
Practice Address - Street 1:2811 QUEENS PLZ N FL 5
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4172
Practice Address - Country:US
Practice Address - Phone:718-391-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723504-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse