Provider Demographics
NPI:1730914474
Name:VILLALBA, ALYSSA (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:VILLALBA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 NW 137TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2610
Mailing Address - Country:US
Mailing Address - Phone:954-303-2474
Mailing Address - Fax:
Practice Address - Street 1:10650 W STATE ROAD 84 STE 208
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:954-424-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9118597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant