Healthcare Provider Details

I. General information

NPI: 1841891447
Provider Name (Legal Business Name): MADISON LYNN MULLINS PA-S2
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax: 813-449-6713
Mailing address:
  • Phone: 813-745-4673
  • Fax: 813-449-6713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9122134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: