MEDICARE: RAY M QUENNEVILLE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1730153875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAY M QUENNEVILLE PA

Provider Business Mailing Address
First Line	:	8121 ISLANDER CT
Second Line	:
City	:	WINDSOR
State	:	CO
Zip	:	80528-8973
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4674 SNOW MESA DR STE 140
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-8614
Country	:	US
Telephone Number	:	970-482-0213
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	11/12/2014

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