Provider Demographics
NPI:1174246631
Name:SANTANA, EMMANUEL AGUSTIN
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:AGUSTIN
Last Name:SANTANA
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 1:55 BANK ST APT 716
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-2021
Mailing Address - Country:US
Mailing Address - Phone:347-322-4303
Mailing Address - Fax:
Practice Address - Street 1:1626 PUTNEY RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1818
Practice Address - Country:US
Practice Address - Phone:718-618-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1635613221171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator