Healthcare Provider Details

I. General information

NPI: 1609096742
Provider Name (Legal Business Name): MAY ROSE VILLASIN KURNIAWAN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS MAY ROSE ABLAO VILLASIN

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W BROADWAY SUITE 100
GLENDALE CA
91204-1331
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 888-727-1771
  • Fax: 818-545-7606
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number17543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: