Provider Demographics
NPI:1598317232
Name:QUINLAN, KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:QUINLAN
Suffix:
Gender:M
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 1:5145 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3661
Mailing Address - Country:US
Mailing Address - Phone:773-989-3800
Mailing Address - Fax:773-907-1005
Practice Address - Street 1:5501 OLD YORK RD STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3098
Practice Address - Country:US
Practice Address - Phone:800-346-7834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060646363AM0700X
IL085008100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical