Provider Demographics
NPI:1467611905
Name:VILLANUEVA, CARL JASON ANTONIL (PT)
Entity Type:Individual
Prefix:MR
First Name:CARL JASON
Middle Name:ANTONIL
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 HUNTERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWAY PARK
Mailing Address - State:NC
Mailing Address - Zip Code:28544-1635
Mailing Address - Country:US
Mailing Address - Phone:910-577-1210
Mailing Address - Fax:
Practice Address - Street 1:1839 ONSLOW DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5906
Practice Address - Country:US
Practice Address - Phone:910-455-3610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist