Healthcare Provider Details

I. General information

NPI: 1528890696
Provider Name (Legal Business Name): JONATHAN DAYNE MULLINAX PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 FOSTER DR STE B
MCDONOUGH GA
30253-5346
US

IV. Provider business mailing address

156 FOSTER DR STE B
MCDONOUGH GA
30253-5346
US

V. Phone/Fax

Practice location:
  • Phone: 770-506-4119
  • Fax: 770-506-4145
Mailing address:
  • Phone: 770-506-4119
  • Fax: 770-506-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14067
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: