Provider Demographics
NPI:1194061192
Name:VILLELLA, DANIEL JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:VILLELLA
Suffix:
Gender:M
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 1:2302 S 1800 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4131
Mailing Address - Country:US
Mailing Address - Phone:801-884-2027
Mailing Address - Fax:
Practice Address - Street 1:8TH AVE & C STREET
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143
Practice Address - Country:US
Practice Address - Phone:801-408-3043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8464779-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant