MEDICARE: MICHAEL R MCMULLIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9486	MN

General Provider Information

NPI Number	:	1518919752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL R MCMULLIN

Provider Business Mailing Address
First Line	:	403 W 4TH ST
Second Line	:
City	:	ST CHARLES
State	:	MN
Zip	:	55972-2127
Country	:	US
Telephone Number	:	507-932-3810
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 W 4TH ST
Second Line	:
City	:	ST CHARLES
State	:	MN
Zip	:	55972-2127
Country	:	US
Telephone Number	:	507-932-3810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	06/06/2013

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Directions to “ MICHAEL R MCMULLIN ” Practice Location

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