Provider Demographics
NPI:1063457893
Name:MULLINIX, MATTHEW (CRNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MULLINIX
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32103
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-2103
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:2100 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2274
Practice Address - Country:US
Practice Address - Phone:800-967-1646
Practice Address - Fax:317-567-2191
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY22560.355367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315565OtherBCBS
WYP00435055OtherRAILROAD MEDICARE
WY1063457893Medicaid
WY1063457893Medicaid
WY21649Medicare PIN