Provider Demographics
NPI:1316909757
Name:VILLANUEVA, MICHAEL VILLAVERDE (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VILLAVERDE
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:VILLAVERDE
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:126 AVOCADO AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2605
Mailing Address - Country:US
Mailing Address - Phone:951-657-0544
Mailing Address - Fax:951-657-9644
Practice Address - Street 1:126 AVOCADO AVE STE 207
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-657-0544
Practice Address - Fax:951-657-9644
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant