Provider Demographics
NPI:1720611106
Name:MULLALY, PATRICK CHARLES (LAC)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:CHARLES
Last Name:MULLALY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:MULLALY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:18 VAN BROOK DR
Mailing Address - Street 2:
Mailing Address - City:STORMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12582-5211
Mailing Address - Country:US
Mailing Address - Phone:347-820-3563
Mailing Address - Fax:
Practice Address - Street 1:18 VAN BROOK DR
Practice Address - Street 2:
Practice Address - City:STORMVILLE
Practice Address - State:NY
Practice Address - Zip Code:12582-5211
Practice Address - Country:US
Practice Address - Phone:347-820-3563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003196-3171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist