Basic Information
Provider Information | |||||||||
NPI: | 1144479254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VILLAMAYOR | ||||||||
FirstName: | FRANK | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 622 COLLINS DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | FESTUS | ||||||||
State: | MO | ||||||||
PostalCode: | 630282077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6366381506 | ||||||||
FaxNumber: | 6366381507 | ||||||||
Practice Location | |||||||||
Address1: | 2865 JAMES BLVD | ||||||||
Address2: |   | ||||||||
City: | POPLAR BLUFF | ||||||||
State: | MO | ||||||||
PostalCode: | 639012803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737761100 | ||||||||
FaxNumber: | 5737761107 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2008 | ||||||||
LastUpdateDate: | 10/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2008002901 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1144479254 | 05 | MO |   | MEDICAID |