Provider Demographics
NPI:1194826230
Name:MCMULLEN, MICHAEL ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MCMULLEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8881 FLETCHER PKWY
Mailing Address - Street 2:SUITE 370
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3134
Mailing Address - Country:US
Mailing Address - Phone:619-462-5555
Mailing Address - Fax:619-462-5572
Practice Address - Street 1:8881 FLETCHER PKWY
Practice Address - Street 2:SUITE 370
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-462-5555
Practice Address - Fax:619-462-5572
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11836363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR40634Medicare UPIN