Healthcare Provider Details

I. General information

NPI: 1568992030
Provider Name (Legal Business Name): WILFREDO AUSTIN VILLARRUBIA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 E HOSPITAL DR STE 550
WEST COLUMBIA SC
29169-4843
US

IV. Provider business mailing address

1100 LONG POND ROAD SUITE 250
ROCHESTER NY
14626-4122
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7140
  • Fax: 803-936-7412
Mailing address:
  • Phone: 585-368-4350
  • Fax: 585-227-7324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number020884
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4990
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: