Provider Demographics
NPI:1710936315
Name:VILLARREAL-GOLBA, TERRY (PA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:VILLARREAL-GOLBA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-9894
Mailing Address - Fax:970-858-1331
Practice Address - Street 1:281 N PLUM ST
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2100
Practice Address - Country:US
Practice Address - Phone:970-858-9894
Practice Address - Fax:970-858-1331
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37125541Medicaid
CO37125541Medicaid
CO543959YYS0Medicare PIN
COP44081Medicare UPIN