Provider Demographics
NPI:1386090561
Name:MALLICK, MUKUL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MUKUL
Middle Name:
Last Name:MALLICK
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4014 CARRIE MILL XING
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-8057
Mailing Address - Country:US
Mailing Address - Phone:480-330-8920
Mailing Address - Fax:804-821-0011
Practice Address - Street 1:1380 N PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5742
Practice Address - Country:US
Practice Address - Phone:048-821-0010
Practice Address - Fax:804-821-0011
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2025-02-04
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Provider Licenses
StateLicense IDTaxonomies
VA0110-005354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant