Provider Demographics
NPI:1891205043
Name:ARCHER, QUENTIN LAWRENCE (PAC)
Entity Type:Individual
Prefix:
First Name:QUENTIN
Middle Name:LAWRENCE
Last Name:ARCHER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:QUENTIN
Other - Middle Name:DOUGLAS
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 GRAY AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1416
Mailing Address - Country:US
Mailing Address - Phone:612-703-1266
Mailing Address - Fax:
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-9360
Practice Address - Fax:315-464-9361
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant