Provider Demographics
NPI:1417356825
Name:MULLEN, MICHAEL EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:MULLEN
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 1:86 THOMAS JOHNSON CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4348
Mailing Address - Country:US
Mailing Address - Phone:301-694-8311
Mailing Address - Fax:301-694-3537
Practice Address - Street 1:86 THOMAS JOHNSON CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4348
Practice Address - Country:US
Practice Address - Phone:301-694-8311
Practice Address - Fax:301-694-3537
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026100207X00000X, 363AS0400X
PAMA056918363A00000X, 363AS0400X
PAOA003308363AS0400X
MDC0005476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA391163OtherMEDICARE ID