Provider Demographics
NPI:1912580168
Name:MULLEN, KATRINA RAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:RAYNE
Last Name:MULLEN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:RAYNE
Other - Last Name:LEZCANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5215 E STATE ROAD 64
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5533
Mailing Address - Country:US
Mailing Address - Phone:941-907-3400
Mailing Address - Fax:
Practice Address - Street 1:5215 E STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5533
Practice Address - Country:US
Practice Address - Phone:971-907-3400
Practice Address - Fax:941-907-4202
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant