Healthcare Provider Details

I. General information

NPI: 1417356825
Provider Name (Legal Business Name): MICHAEL EDWARD MULLEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 THOMAS JOHNSON CT
FREDERICK MD
21702-4348
US

IV. Provider business mailing address

86 THOMAS JOHNSON CT
FREDERICK MD
21702-4348
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-8311
  • Fax: 301-694-3537
Mailing address:
  • Phone: 301-694-8311
  • Fax: 301-694-3537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number026100
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA056918
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberOA003308
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA056918
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number026100
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005476
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: