Basic Information
| Provider Information | |||||||||
| NPI: | 1659410991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | JOAN | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 4244 RIVERWALK PKWY | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925058509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517367432 | ||||||||
| FaxNumber: | 9517367751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP14831 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P01080865 | 01 | CA | RR MEDICARE - SO CALIF | OTHER |