MEDICARE: LORENA ALICIA VILLARREAL DE CANTU PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	8085892-1206	UT

General Provider Information

NPI Number	:	1679840599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORENA ALICIA VILLARREAL DE CANTU PA

Provider Business Mailing Address
First Line	:	2240 ADAMS AVE
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84401-1511
Country	:	US
Telephone Number	:	801-393-5355
Fax Number	:	801-394-4609

Provider Business Practice Location Address
First Line	:	5285 S 400 E
Second Line	:
City	:	WASHINGTON TERRACE
State	:	UT
Zip	:	84405-7194
Country	:	US
Telephone Number	:	801-393-5355
Fax Number	:	801-394-4609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	11/21/2011

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