Provider Demographics
NPI:1790999423
Name:PULLEN, VIRGINIA K (PA-C)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:K
Last Name:PULLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:BROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:108 CAPE CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32413-5206
Mailing Address - Country:US
Mailing Address - Phone:850-532-3430
Mailing Address - Fax:
Practice Address - Street 1:2306 HWY 77
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4404
Practice Address - Country:US
Practice Address - Phone:850-763-9744
Practice Address - Fax:850-785-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.165363A00000X
FL9104277363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant