Healthcare Provider Details

I. General information

NPI: 1699146100
Provider Name (Legal Business Name): JASON WESLEY MULLINS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 LOUISA ROAD
CATLETTSBURG KY
41129-1091
US

IV. Provider business mailing address

P. O. BOX 1595
ASHLAND KY
41105-1595
US

V. Phone/Fax

Practice location:
  • Phone: 606-739-6095
  • Fax: 606-739-8252
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2046
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: