Provider Demographics
NPI:1427342187
Name:MULL, KEITH BRIAN (SA)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:BRIAN
Last Name:MULL
Suffix:
Gender:M
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1522
Mailing Address - Country:US
Mailing Address - Phone:240-446-6936
Mailing Address - Fax:
Practice Address - Street 1:5759 CEDAR LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2912
Practice Address - Country:US
Practice Address - Phone:410-740-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2011-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
MS20282246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist