Provider Demographics
NPI:1205318938
Name:VILLAVICENCIO, CARISSA LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:LEIGH
Last Name:VILLAVICENCIO
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 1:27898 SKYCREST CIR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-1415
Mailing Address - Country:US
Mailing Address - Phone:661-904-0943
Mailing Address - Fax:
Practice Address - Street 1:655 W AVENUE Q
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3894
Practice Address - Country:US
Practice Address - Phone:661-259-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant