Provider Demographics
NPI:1265627996
Name:MULLIS, SHARON MARIE (DO)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:MARIE
Last Name:MULLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:MARIE
Other - Last Name:MULLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:200 EMILIO LOPEZ RD NW
Practice Address - Street 2:PMG LOS LUNAS
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6818
Practice Address - Country:US
Practice Address - Phone:505-866-2700
Practice Address - Fax:505-866-2701
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3834207Q00000X
NMA-1536-10207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18503829Medicaid
NMNM303147Medicare PIN