Healthcare Provider Details

I. General information

NPI: 1720314362
Provider Name (Legal Business Name): JORGE VILLARREAL LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2009
Last Update Date: 10/13/2021
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 SHAFTSBURY DR
CORPUS CHRISTI TX
78415-4483
US

IV. Provider business mailing address

2425 SHAFTSBURY DR
CORPUS CHRISTI TX
78415-4483
US

V. Phone/Fax

Practice location:
  • Phone: 361-459-9680
  • Fax:
Mailing address:
  • Phone: 361-459-9680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00550
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: