Provider Demographics
NPI:1053302364
Name:MULDER, JOHN (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MULDER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 LINN ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:269-686-5800
Mailing Address - Fax:269-686-5899
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:269-686-5877
Practice Address - Fax:269-686-5896
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJM002434OtherSTATE LICENSE #
R86050Medicare UPIN
MIP39040008Medicare PIN
Z36002P04Medicare ID - Type Unspecified