Provider Demographics
NPI:1134382922
Name:VILLALOBOS, JUDY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:
Last Name:VILLALOBOS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:305-436-1563
Mailing Address - Fax:305-436-1564
Practice Address - Street 1:9655 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2973
Practice Address - Country:US
Practice Address - Phone:305-436-1563
Practice Address - Fax:305-436-1564
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104568363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002807900Medicaid