Healthcare Provider Details

I. General information

NPI: 1427981240
Provider Name (Legal Business Name): MADELINE MARIE MULLIGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 STOVALL ST
BULLHEAD CITY AZ
86442-8780
US

IV. Provider business mailing address

1820 STOVALL ST
BULLHEAD CITY AZ
86442-8780
US

V. Phone/Fax

Practice location:
  • Phone: 928-278-2963
  • Fax:
Mailing address:
  • Phone: 928-278-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11683
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: