Provider Demographics
NPI:1760281299
Name:BRUST, NICHOLAS QUINN (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:QUINN
Last Name:BRUST
Suffix:
Gender:M
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 1:779 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-3509
Mailing Address - Country:US
Mailing Address - Phone:830-734-6667
Mailing Address - Fax:
Practice Address - Street 1:601 E ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4740
Practice Address - Country:US
Practice Address - Phone:630-206-5574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-08
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085011281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty