Provider Demographics
NPI:1407592934
Name:QUINTANA, RAIDON
Entity Type:Individual
Prefix:
First Name:RAIDON
Middle Name:
Last Name:QUINTANA
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 1:210 MULBERRY WOODS CT
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-1507
Mailing Address - Country:US
Mailing Address - Phone:559-347-8807
Mailing Address - Fax:
Practice Address - Street 1:210 MULBERRY WOODS CT
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77318-1507
Practice Address - Country:US
Practice Address - Phone:559-347-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-08
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer