Provider Demographics
NPI:1093337834
Name:RODRIGUEZ, QUILVIO ANTONIO (PMHNP-BC, RN)
Entity Type:Individual
Prefix:DR
First Name:QUILVIO
Middle Name:ANTONIO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2562
Mailing Address - Country:US
Mailing Address - Phone:718-364-7700
Mailing Address - Fax:
Practice Address - Street 1:154 W 127TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3739
Practice Address - Country:US
Practice Address - Phone:212-749-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703575163WP0809X
NYF403045-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY703575Medicaid