Basic Information
| Provider Information | |||||||||
| NPI: | 1588628333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUINLAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177892336 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 N PEARL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023011794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084272335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 252322 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0701696 | 05 | MA | MEDICAID |