Provider Demographics
NPI:1861074197
Name:SANTIAGO, JERRY
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12421 PASEO ALEGRE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79928-5664
Mailing Address - Country:US
Mailing Address - Phone:915-491-6447
Mailing Address - Fax:
Practice Address - Street 1:12421 PASEO ALEGRE DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79928-5664
Practice Address - Country:US
Practice Address - Phone:915-491-6447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84-2405239OtherDEPARTMENT OF THE TREASURY