Provider Demographics
NPI:1477847010
Name:VILLANUEVA, LAURA A (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:HOLDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:130 E VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2246
Mailing Address - Country:US
Mailing Address - Phone:970-641-0211
Mailing Address - Fax:970-641-1268
Practice Address - Street 1:130 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2246
Practice Address - Country:US
Practice Address - Phone:970-641-0211
Practice Address - Fax:970-641-1268
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95300040Medicaid