Healthcare Provider Details

I. General information

NPI: 1255303525
Provider Name (Legal Business Name): ANDRE MUELENAER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HIGHLAND AVE SE SUITE 203
ROANOKE VA
24013-2256
US

IV. Provider business mailing address

102 HIGHLAND AVE SE SUITE 203
ROANOKE VA
24013-2256
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-9835
  • Fax: 540-985-4018
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101-047216
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number29353
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number0101-047216
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29353
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: