Healthcare Provider Details

I. General information

NPI: 1275999799
Provider Name (Legal Business Name): MR. NATHAN MULLINS I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

735 WALL ST APT #1
PORT HURON MI
48060-5377
US

V. Phone/Fax

Practice location:
  • Phone: 810-966-4459
  • Fax:
Mailing address:
  • Phone: 810-887-8801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number175T00000X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: