Provider Demographics
NPI:1689611469
Name:MULLIGAN, JOSEPH MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:MULLIGAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 LAKE FRONT RD.
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754
Mailing Address - Country:US
Mailing Address - Phone:270-230-0377
Mailing Address - Fax:
Practice Address - Street 1:515 LAKE FRONT RD.
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754
Practice Address - Country:US
Practice Address - Phone:270-230-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28092549A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN360955OtherIN BCBS ANTHEM PROVIDER #
IN10001010Medicaid
IN223090DMedicare ID - Type UnspecifiedIN MCARE PROVIDER #