Provider Demographics
NPI:1124505706
Name:MULLEN, KRISTINA (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
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 1:426 COUNSELORS WAY APT 307
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8635
Mailing Address - Country:US
Mailing Address - Phone:803-371-7217
Mailing Address - Fax:
Practice Address - Street 1:280 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1838
Practice Address - Country:US
Practice Address - Phone:704-948-8699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant