Provider Demographics
NPI:1447649181
Name:SANTIAGO, MYRA
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:MENESES
Other - Last Name:NINING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1166 WIND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2898
Mailing Address - Country:US
Mailing Address - Phone:619-348-2416
Mailing Address - Fax:
Practice Address - Street 1:1166 WIND RIVER RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-2898
Practice Address - Country:US
Practice Address - Phone:619-348-2416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8690225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant