Healthcare Provider Details

I. General information

NPI: 1659262483
Provider Name (Legal Business Name): COLLIN QUINLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 JOHN KISSINGER DR
WABASH IN
46992-1648
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-563-7451
  • Fax: 260-569-2284
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005057A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: