Provider Demographics
NPI:1376931675
Name:VILLASISTA, PETER P
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:VILLASISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N CORONADO ST APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-3966
Mailing Address - Country:US
Mailing Address - Phone:323-529-7545
Mailing Address - Fax:
Practice Address - Street 1:631 N CORONADO ST APT 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-3966
Practice Address - Country:US
Practice Address - Phone:323-529-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT10613225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant