Provider Demographics
NPI:1689682759
Name:MULLEN, JOHN EDWARD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:MULLEN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 KENNER RD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5265
Mailing Address - Country:US
Mailing Address - Phone:936-639-2694
Mailing Address - Fax:
Practice Address - Street 1:1301 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3305
Practice Address - Country:US
Practice Address - Phone:936-633-2791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00755363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical