Provider Demographics
NPI:1316768203
Name:QUALLS, PAUL R JR
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:R
Last Name:QUALLS
Suffix:JR
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 1:586 MERRITT MORNING WAY APT 206
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-2876
Mailing Address - Country:US
Mailing Address - Phone:843-213-8131
Mailing Address - Fax:407-795-0412
Practice Address - Street 1:586 MERRITT MORNING WAY APT 206
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-2876
Practice Address - Country:US
Practice Address - Phone:843-213-8131
Practice Address - Fax:407-795-0412
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker