Healthcare Provider Details

I. General information

NPI: 1457284499
Provider Name (Legal Business Name): MARK VILLANUEVA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 CALLE DE LA PLATA STE 400
LAGUNA HILLS CA
92653-7623
US

IV. Provider business mailing address

24012 CALLE DE LA PLATA STE 400
LAGUNA HILLS CA
92653-7623
US

V. Phone/Fax

Practice location:
  • Phone: 949-354-5328
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number11060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: