Provider Demographics
NPI:1760996383
Name:DE VILLIERS, ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:DE VILLIERS
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 1:560 N CAMINO MERCADO STE 7
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5759
Mailing Address - Country:US
Mailing Address - Phone:520-836-5538
Mailing Address - Fax:
Practice Address - Street 1:81 W GUADALUPE RD STE 111
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3321
Practice Address - Country:US
Practice Address - Phone:480-366-4489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7020363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant