Provider Demographics
NPI:1679840599
Name:VILLARREAL DE CANTU, LORENA ALICIA (PA)
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:ALICIA
Last Name:VILLARREAL DE CANTU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-393-5355
Mailing Address - Fax:801-394-4609
Practice Address - Street 1:5285 S 400 E
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-7194
Practice Address - Country:US
Practice Address - Phone:801-393-5355
Practice Address - Fax:801-394-4609
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8085892-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant