Healthcare Provider Details

I. General information

NPI: 1871629477
Provider Name (Legal Business Name): ATHENA VILLASENOR TAYLAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ATHENA SILVA VILLASENOR MD

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 MOUNTAIN RANCH RD
SAN ANDREAS CA
95249-9707
US

IV. Provider business mailing address

4694 GRESHAM DR
EL DORADO HILLS CA
95762-7624
US

V. Phone/Fax

Practice location:
  • Phone: 209-736-0813
  • Fax: 209-736-9088
Mailing address:
  • Phone: 916-941-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA066587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: