Provider Demographics
NPI:1871669796
Name:MULL, KEVIN RONALD (PAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RONALD
Last Name:MULL
Suffix:
Gender:M
Credentials:PAC
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 276
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21826-0276
Mailing Address - Country:US
Mailing Address - Phone:410-713-2515
Mailing Address - Fax:410-651-0303
Practice Address - Street 1:1675 WOODBROOKE DRIVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-749-4154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000684363A00000X
MDC0002049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant