Provider Demographics
NPI:1790213692
Name:VILLANUEVA, WESLEY (PA)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 DEEP LAKE RD
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5240
Mailing Address - Country:US
Mailing Address - Phone:407-366-9800
Mailing Address - Fax:321-203-4604
Practice Address - Street 1:5409 DEEP LAKE RD
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5240
Practice Address - Country:US
Practice Address - Phone:407-366-9800
Practice Address - Fax:321-203-4604
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9110797363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant