Healthcare Provider Details

I. General information

NPI: 1659451201
Provider Name (Legal Business Name): RYAN HENRY VILLAMATER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UCLA MEDICAL PLZ STE 630
LOS ANGELES CA
90024-6997
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9011
  • Fax:
Mailing address:
  • Phone: 310-825-9820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA19639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: