Provider Demographics
NPI:1043691314
Name:VILLARREAL, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 S SHERIDAN BLVD DEPT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80232-8022
Mailing Address - Country:US
Mailing Address - Phone:303-233-4671
Mailing Address - Fax:303-935-7597
Practice Address - Street 1:1214 S SHERIDAN BLVD DEPT
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80232-8022
Practice Address - Country:US
Practice Address - Phone:303-233-4671
Practice Address - Fax:303-935-7597
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38135043Medicaid
CO38135043Medicaid