Provider Demographics
NPI:1255737631
Name:VILLANUEVA, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-8800
Mailing Address - Fax:704-632-4001
Practice Address - Street 1:200 SOUTH COLLEGE STREET
Practice Address - Street 2:SUITE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2067
Practice Address - Country:US
Practice Address - Phone:704-302-8800
Practice Address - Fax:704-632-4001
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5841363LF0000X
NC285489363LF0000X
NC5008751363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4174Medicaid
NC1255737631Medicaid
SCNP4174Medicaid