Provider Demographics
NPI:1033118237
Name:VILLAVERDE, RAYMOND A (PA)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:A
Last Name:VILLAVERDE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 JADE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-3956
Mailing Address - Country:US
Mailing Address - Phone:831-475-4344
Mailing Address - Fax:831-475-4344
Practice Address - Street 1:4140 JADE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3956
Practice Address - Country:US
Practice Address - Phone:831-475-4344
Practice Address - Fax:831-475-4344
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001011364SM0705X
CAPA21732363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
201900Medicare ID - Type Unspecified
IL5413370001Medicare NSC
P59612Medicare UPIN