Provider Demographics
NPI:1821091547
Name:MULLANE, MARILYN KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:KAY
Last Name:MULLANE
Suffix:
Gender:F
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-766-0547
Mailing Address - Fax:336-766-0549
Practice Address - Street 1:390 W SALEM AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5861
Practice Address - Country:US
Practice Address - Phone:336-721-2375
Practice Address - Fax:336-721-2394
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101138363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101706Medicaid
NC2799041EMedicare PIN
S70974Medicare UPIN
2799041CMedicare ID - Type Unspecified