Provider Demographics
NPI:1255638870
Name:VILLARET, AMY MARIE (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:VILLARET
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:CZESNOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:925 TAHOE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-7498
Practice Address - Country:US
Practice Address - Phone:775-580-7600
Practice Address - Fax:775-831-0946
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1281363A00000X
CAPA21440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEZ514ZMedicare PIN