Provider Demographics
NPI:1396496436
Name:QUACKENBUSH, BRYAN HOWARD
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:HOWARD
Last Name:QUACKENBUSH
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 1:105 BELVEDERE RD
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-2421
Mailing Address - Country:US
Mailing Address - Phone:845-264-9708
Mailing Address - Fax:
Practice Address - Street 1:750 BERME RD
Practice Address - Street 2:
Practice Address - City:NAPANOCH
Practice Address - State:NY
Practice Address - Zip Code:12458-2709
Practice Address - Country:US
Practice Address - Phone:845-647-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN676013163W00000X
NY702414163W00000X
NY404392363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse