Provider Demographics
NPI:1477560266
Name:MCMULLAN, AMBER GAYLE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:GAYLE
Last Name:MCMULLAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:AMBER
Other - Middle Name:GAYLE
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2525 N GRANDVIEW AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1621
Mailing Address - Country:US
Mailing Address - Phone:432-550-4700
Mailing Address - Fax:432-550-4715
Practice Address - Street 1:1901 W HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-3311
Practice Address - Country:US
Practice Address - Phone:432-837-5918
Practice Address - Fax:432-837-9937
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1167940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366720601Medicaid
TX8TAE46OtherBLUE CROSS BLUE SHIELD TEXAS
TX396827YLJGMedicare PIN