Provider Demographics
NPI:1063443992
Name:MULLEN, ANDREW IVAN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:IVAN
Last Name:MULLEN
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E HURON ST
Mailing Address - Street 2:SUITE 10-200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-926-3535
Mailing Address - Fax:312-926-3585
Practice Address - Street 1:201 E HURON ST
Practice Address - Street 2:SUITE 10-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-926-3535
Practice Address - Fax:312-926-3585
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212210001Medicare PIN
ILP00066388Medicare PIN
ILQ05803Medicare UPIN
ILK03336Medicare ID - Type Unspecified