Provider Demographics
NPI:1083186639
Name:VILLANUEVA, CRESOLITO ALCANTARA JR
Entity type:Individual
Prefix:MR
First Name:CRESOLITO
Middle Name:ALCANTARA
Last Name:VILLANUEVA
Suffix:JR
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 1:2339 W HAMMER LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-2368
Mailing Address - Country:US
Mailing Address - Phone:209-940-5901
Mailing Address - Fax:
Practice Address - Street 1:2339 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2368
Practice Address - Country:US
Practice Address - Phone:209-940-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily