Healthcare Provider Details

I. General information

NPI: 1043093230
Provider Name (Legal Business Name): COLLEEN RITA QUICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 KINGSBOROUGH SQ STE 100
CHESAPEAKE VA
23320-5041
US

IV. Provider business mailing address

612 KINGSBOROUGH SQ STE 100
CHESAPEAKE VA
23320-5041
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-9294
  • Fax: 757-213-9342
Mailing address:
  • Phone: 757-547-9294
  • Fax: 757-213-9342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1210557
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009692
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: