Basic Information
| Provider Information | |||||||||
| NPI: | 1659572592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLALOBOS | ||||||||
| FirstName: | TYRA | ||||||||
| MiddleName: | MONIQUE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 DIVISADERO ST | ||||||||
| Address2: | #100 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575500 | ||||||||
| FaxNumber: | 5594575896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1945 N FINE AVE STE 116 | ||||||||
| Address2: | HUMAN RESOURCES | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575231 | ||||||||
| FaxNumber: | 5594575896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LF0000X | 19045 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.