Healthcare Provider Details

I. General information

NPI: 1497513931
Provider Name (Legal Business Name): MICHAEL VILLAS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5627 S 11TH ST
GRAND FORKS ND
58201-3632
US

IV. Provider business mailing address

534 OREGON AVE SE
HURON SD
57350-2801
US

V. Phone/Fax

Practice location:
  • Phone: 701-330-4510
  • Fax:
Mailing address:
  • Phone: 605-353-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1497513931
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: