Provider Demographics
NPI:1497841506
Name:MCMULLEN, JOHN R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:MCMULLEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:MCMULLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:333 N 17TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-2423
Mailing Address - Country:US
Mailing Address - Phone:480-278-2100
Mailing Address - Fax:
Practice Address - Street 1:333 N 17TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-2423
Practice Address - Country:US
Practice Address - Phone:480-278-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3613363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3613OtherPA LICENSE