Provider Demographics
NPI:1760632822
Name:MCMULLIN, ALAN WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:WILLIAM
Last Name:MCMULLIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4529
Mailing Address - Country:US
Mailing Address - Phone:217-679-1695
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003330363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207236005Medicare PIN