Healthcare Provider Details

I. General information

NPI: 1386487544
Provider Name (Legal Business Name): JULISSA QUINTANILLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 SW CENTER ST
FAISON NC
28341-8820
US

IV. Provider business mailing address

PO BOX 187
FAISON NC
28341-0187
US

V. Phone/Fax

Practice location:
  • Phone: 910-267-0421
  • Fax: 910-378-1746
Mailing address:
  • Phone: 910-267-2042
  • Fax: 855-996-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14568
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: