Healthcare Provider Details

I. General information

NPI: 1104485184
Provider Name (Legal Business Name): CARLOS DANIEL VILLALPANDO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14520 W GRANITE VALLEY DR STE 210
SUN CITY WEST AZ
85375-5855
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10240
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-001423
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: