Basic Information
| Provider Information | |||||||||
| NPI: | 1184926602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 510 | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989440510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 208 N EUCLID RD | ||||||||
| Address2: | |||||||||
| City: | GRANDVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989309470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098821855 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2010 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | MD60395006 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207RS0012X | MD60395006 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
No ID Information.