Provider Demographics
NPI:1720147515
Name:VILA, MANUEL M (PA)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:M
Last Name:VILA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8102 NW 158TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-7119
Mailing Address - Country:US
Mailing Address - Phone:305-586-0717
Mailing Address - Fax:305-819-9714
Practice Address - Street 1:8102 NW 158TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-7119
Practice Address - Country:US
Practice Address - Phone:305-586-0717
Practice Address - Fax:305-819-9714
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100758363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290869700Medicaid
FLE1235ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER
FL290869700Medicaid