Provider Demographics
NPI:1851023410
Name:VILLALTA, GENESEE MAYLEE (PA-C)
Entity Type:Individual
Prefix:
First Name:GENESEE
Middle Name:MAYLEE
Last Name:VILLALTA
Suffix:
Gender:F
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 1:427 DARWIN ST # B
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2628
Mailing Address - Country:US
Mailing Address - Phone:707-360-8184
Mailing Address - Fax:
Practice Address - Street 1:1510 CAPITOLA RD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2912
Practice Address - Country:US
Practice Address - Phone:831-427-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
CA61474363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)