Provider Demographics
NPI:1851485072
Name:MULLIGAN, IVAN (PT, SCS, ATC)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MULLIGAN
Suffix:
Gender:M
Credentials:PT, SCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2646
Mailing Address - Country:US
Mailing Address - Phone:814-254-0086
Mailing Address - Fax:
Practice Address - Street 1:515 STATE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2646
Practice Address - Country:US
Practice Address - Phone:814-254-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA008858-L2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic