Basic Information
| Provider Information | |||||||||
| NPI: | 1164419156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLARREAL | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616640145 | ||||||||
| FaxNumber: | 3616642248 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S HILLSIDE DR | ||||||||
| Address2: | SUITES 5,6,15 | ||||||||
| City: | BEEVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781025307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613620307 | ||||||||
| FaxNumber: | 3613620221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C03187 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 201815201 | 05 | TX | MEDICAID |