MEDICARE: KYLIE LAUREN VILLEGAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	PA15623	TX

General Provider Information

NPI Number	:	1700552791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLIE LAUREN VILLEGAS

Provider Business Mailing Address
First Line	:	3698 CHAMBERS PASS BLDG 3611
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7766
Country	:	US
Telephone Number	:	210-916-5658
Fax Number	:	210-271-0830

Provider Business Practice Location Address
First Line	:	9898 COLONNADE BLVD APT 6207
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-2271
Country	:	US
Telephone Number	:	361-550-8412
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2021
Last Update Date	:	07/19/2022

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