Provider Demographics
NPI:1598150195
Name:BANDOQUILLO, KIRBY (NP)
Entity type:Individual
Prefix:
First Name:KIRBY
Middle Name:
Last Name:BANDOQUILLO
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S TRYON ST STE 440
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3271
Mailing Address - Country:US
Mailing Address - Phone:704-626-6266
Mailing Address - Fax:
Practice Address - Street 1:135 W 10TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2229
Practice Address - Country:US
Practice Address - Phone:704-626-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018543363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care