Healthcare Provider Details

I. General information

NPI: 1255638870
Provider Name (Legal Business Name): AMY MARIE VILLARET PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY MARIE CZESNOWSKI PA

II. Dates (important events)

Enumeration Date: 02/16/2011
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 TAHOE BLVD STE 105
INCLINE VILLAGE NV
89451-7498
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 775-580-7600
  • Fax: 775-831-0946
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1281
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21440
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: