Provider Demographics
NPI:1952393381
Name:VILLARREAL, CHRISTOPHER (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:VILLARREAL
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:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-0518
Mailing Address - Country:US
Mailing Address - Phone:580-298-3341
Mailing Address - Fax:580-298-2206
Practice Address - Street 1:510 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-3262
Practice Address - Country:US
Practice Address - Phone:580-298-3341
Practice Address - Fax:580-298-2206
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1691888363AM0700X
TXPA05868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100159270AMedicaid
OK1691888OtherSTATE LICENSE
TX8L18867Medicare PIN
TX8L18885Medicare PIN
OK244502506Medicare ID - Type Unspecified
OKS87627Medicare UPIN
OK1691888OtherSTATE LICENSE