Provider Demographics
NPI:1992324321
Name:MULIC, IBRAHIM
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:MULIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 CAMINITO ANDRETA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7203
Mailing Address - Country:US
Mailing Address - Phone:619-228-4717
Mailing Address - Fax:
Practice Address - Street 1:1742 OREGON ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1717
Practice Address - Country:US
Practice Address - Phone:619-228-4717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant