Basic Information
| Provider Information | |||||||||
| NPI: | 1659451201 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VILLAMATER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900953075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA19639 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0PA196390 | 05 | CA | MEDICAID |