Provider Demographics
NPI:1083411326
Name:QUINTANILLA, RICARDO (PA-C)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:QUINTANILLA
Suffix:
Gender:
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 1:170 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2198
Mailing Address - Country:US
Mailing Address - Phone:631-208-4460
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 276
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-0226
Practice Address - Country:US
Practice Address - Phone:516-912-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant