Healthcare Provider Details

I. General information

NPI: 1750879466
Provider Name (Legal Business Name): PETER MICHAEL MULLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2529 NE 139TH ST
VANCOUVER WA
98686-2719
US

IV. Provider business mailing address

PO BOX 4825
PORTLAND OR
97208-4825
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax:
Mailing address:
  • Phone: 360-882-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD61384668
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMD61384668
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: