Provider Demographics
NPI:1114275377
Name:MULADORE, DANIEL THOMAS (MSPA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:MULADORE
Suffix:
Gender:M
Credentials:MSPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SIXTH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2701
Mailing Address - Country:US
Mailing Address - Phone:231-935-5730
Mailing Address - Fax:
Practice Address - Street 1:1221 SIXTH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2701
Practice Address - Country:US
Practice Address - Phone:231-935-5730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant