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General NPI Number Information
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NPI Number | 1861895013
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Entity Type | Individual
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Provider Name | GARY PAUL QUILLEN ANP
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Gender | Male
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Dates
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Enumeration Date | 10/02/2014
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Last Update Date | 09/24/2019
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Provider Practice Location Address
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Address Line | 1068 S WOODS MILL RD STE 220
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City | TOWN AND COUNTRY
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State | MO
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Zip | 63017-8333
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Country | US
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Telephone | 314-394-1379
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Fax | 314-394-1377
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Provider Business Mailing Address
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Address Line | 1068 S WOODS MILL RD STE 220
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City | TOWN AND COUNTRY
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State | MO
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Zip | 63017-8333
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Country | US
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Telephone | 314-394-1379
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Fax | 314-394-1377
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | AG1014022
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | AG1014022
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License Number State | MO
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