Provider Demographics
NPI:1467484022
Name:LINDQUIST, KELLY (PA C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LINDQUIST
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06085
Mailing Address - Country:US
Mailing Address - Phone:860-673-6124
Mailing Address - Fax:860-673-3290
Practice Address - Street 1:101 MAIN STREET
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:CT
Practice Address - Zip Code:06085
Practice Address - Country:US
Practice Address - Phone:860-673-6124
Practice Address - Fax:860-673-3290
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q32622Medicare UPIN