Healthcare Provider Details

I. General information

NPI: 1396945135
Provider Name (Legal Business Name): JONATHAN T MULLIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 FORSYTH ST STE 2D
MACON GA
31201-8639
US

IV. Provider business mailing address

1062 FORSYTH ST STE 2D
MACON GA
31201-8639
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-8391
  • Fax:
Mailing address:
  • Phone: 478-633-8391
  • Fax: 478-633-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005099
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005099
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: