Healthcare Provider Details

I. General information

NPI: 1578793840
Provider Name (Legal Business Name): AESTHETIC ANESTHESIA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RIVERWOOD RD
MOORESVILLE NC
28117-8896
US

IV. Provider business mailing address

340 RIVERWOOD RD
MOORESVILLE NC
28117-8896
US

V. Phone/Fax

Practice location:
  • Phone: 704-928-5174
  • Fax: 704-660-6946
Mailing address:
  • Phone: 704-928-5174
  • Fax: 704-660-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01754
License Number StateNC

VIII. Authorized Official

Name: JONATHAN N MCMULLEN
Title or Position: PRESIDENT
Credential: MD
Phone: 704-928-5174