Provider Demographics
NPI:1124844352
Name:VILLARREAL, KAITLYN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 S MARION RD APT 410
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-6718
Mailing Address - Country:US
Mailing Address - Phone:605-270-6265
Mailing Address - Fax:
Practice Address - Street 1:5300 S MARION RD APT 410
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6718
Practice Address - Country:US
Practice Address - Phone:605-270-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant