Provider Demographics
NPI:1366496911
Name:MULLIN, DERRICK JOHN (FNP)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:JOHN
Last Name:MULLIN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7894 TIGERWOODS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95829-6602
Mailing Address - Country:US
Mailing Address - Phone:916-682-7702
Mailing Address - Fax:
Practice Address - Street 1:7501 HOSPITAL DR
Practice Address - Street 2:SUITE 205
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5405
Practice Address - Country:US
Practice Address - Phone:916-689-2121
Practice Address - Fax:916-689-2198
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ154962Medicare ID - Type Unspecified
CAS68097Medicare UPIN