Provider Demographics
NPI:1609096742
Name:KURNIAWAN, MAY ROSE VILLASIN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MAY ROSE
Middle Name:VILLASIN
Last Name:KURNIAWAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:MAY ROSE
Other - Middle Name:ABLAO
Other - Last Name:VILLASIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3038 SUNNY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-1492
Mailing Address - Country:US
Mailing Address - Phone:909-464-0558
Mailing Address - Fax:909-464-0558
Practice Address - Street 1:225 W BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1331
Practice Address - Country:US
Practice Address - Phone:888-727-1771
Practice Address - Fax:818-545-7606
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17543363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant