Provider Demographics
NPI:1376903948
Name:MCQUILKIN, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MCQUILKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 VIA ROYALE
Mailing Address - Street 2:1813
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-6984
Mailing Address - Country:US
Mailing Address - Phone:917-916-2456
Mailing Address - Fax:
Practice Address - Street 1:1800 VIA ROYALE
Practice Address - Street 2:1813
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:917-916-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9364271163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
BMC019713314259OtherBLUE CROSS BLUE SHIELD