Provider Demographics
NPI:1174149389
Name:SEGURA BARRON, SANTIAGO A (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:A
Last Name:SEGURA BARRON
Suffix:
Gender:M
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:THANIA
Other - Middle Name:D
Other - Last Name:SEGURA BARRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:641 W BONNEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3338
Mailing Address - Country:US
Mailing Address - Phone:641-295-2760
Mailing Address - Fax:
Practice Address - Street 1:HOLT ARENA 550 MEMORIAL DRIVE BUILDING 50
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-3408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-7512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer