Provider Demographics
NPI:1164419156
Name:VILLARREAL, MARISSA J (PA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:J
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:204 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-4822
Mailing Address - Country:US
Mailing Address - Phone:361-664-0145
Mailing Address - Fax:361-664-2248
Practice Address - Street 1:301 S HILLSIDE DR
Practice Address - Street 2:SUITES 5,6,15
Practice Address - City:BEEVILLE
Practice Address - State:TX
Practice Address - Zip Code:78102-5307
Practice Address - Country:US
Practice Address - Phone:361-362-0307
Practice Address - Fax:361-362-0221
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC03187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201815201Medicaid
TX266245YM3QMedicare Oscar/Certification
FLQ55895Medicare UPIN
FLU6681YMedicare PIN