Healthcare Provider Details

I. General information

NPI: 1184705212
Provider Name (Legal Business Name): VILA PHOULAVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MILVIA ST
BERKELEY CA
94704-2636
US

IV. Provider business mailing address

6220 FAIRLANE DR UNIT B
OAKLAND CA
94611-1810
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-5514
  • Fax:
Mailing address:
  • Phone: 510-735-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number17855
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: