Provider Demographics
NPI:1215665591
Name:VILLARREAL, SELENA MARIE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:MARIE
Last Name:VILLARREAL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-2909
Mailing Address - Country:US
Mailing Address - Phone:956-665-7049
Mailing Address - Fax:
Practice Address - Street 1:12047 POTRANCO RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-7555
Practice Address - Country:US
Practice Address - Phone:210-571-1338
Practice Address - Fax:210-571-1339
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant