Provider Demographics
NPI:1568992030
Name:VILLARRUBIA, WILFREDO AUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:AUSTIN
Last Name:VILLARRUBIA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LONG POND ROAD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-368-4350
Mailing Address - Fax:585-227-7324
Practice Address - Street 1:1100 LONG POND RD STE 250
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-1186
Practice Address - Country:US
Practice Address - Phone:585-368-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020884363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04794932Medicaid