Provider Demographics
NPI:1518079961
Name:QUILLEN, ROCKY CAROL (PA)
Entity Type:Individual
Prefix:
First Name:ROCKY
Middle Name:CAROL
Last Name:QUILLEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 BRAGG DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-6942
Mailing Address - Country:US
Mailing Address - Phone:910-616-5718
Mailing Address - Fax:910-754-2251
Practice Address - Street 1:341 WHITEVILLE RD NW
Practice Address - Street 2:SUITE A
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4507
Practice Address - Country:US
Practice Address - Phone:910-754-8731
Practice Address - Fax:910-754-2251
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant