Provider Demographics
NPI:1457233264
Name:PAGAN MONTALVO, JERALISSE
Entity type:Individual
Prefix:
First Name:JERALISSE
Middle Name:
Last Name:PAGAN MONTALVO
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:B5 TABONUCO STREET
Mailing Address - Street 2:SUITE 216 PMB 133
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968-3029
Mailing Address - Country:US
Mailing Address - Phone:787-364-6944
Mailing Address - Fax:
Practice Address - Street 1:29 CALLE BASILIO CATALA APT 110
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00971-7602
Practice Address - Country:US
Practice Address - Phone:787-364-6944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000466-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant