Basic Information
| Provider Information | |||||||||
| NPI: | 1710456157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLARRAGA | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | EDISON | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26067 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841260067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240400 | ||||||||
| FaxNumber: | 2396240401 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 7TH ST N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396248250 | ||||||||
| FaxNumber: | 2396248251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2018 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APRN9361615 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | ARNP9361615 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NND5J | 01 | FL | BCBS | OTHER | 105699600 | 05 | FL | MEDICAID |