Healthcare Provider Details

I. General information

NPI: 1093245409
Provider Name (Legal Business Name): JAMES MICHAEL MCMULLEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

4412 BARKINGDALE DR
VIRGINIA BEACH VA
23462-4648
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-9102
  • Fax: 757-473-9102
Mailing address:
  • Phone: 757-473-9102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110-005783
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: