Basic Information
| Provider Information | |||||||||
| NPI: | 1598150195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDOQUILLO | ||||||||
| FirstName: | KIRBY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 STONEFOREST DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301894881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783881621 | ||||||||
| FaxNumber: | 6783881627 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 WHITCHER ST NE STE 3110 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222326 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN221793 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.