Provider Demographics
NPI:1033511035
Name:VILLANUEVA, PHILLIP JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOHN
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 - LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:5301 E HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-8676
Practice Address - Fax:734-712-3855
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant