Provider Demographics
NPI:1750415691
Name:MULLINIX, MAGEN (PA-C)
Entity type:Individual
Prefix:
First Name:MAGEN
Middle Name:
Last Name:MULLINIX
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 1:881 GOSHEN RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-9654
Mailing Address - Country:US
Mailing Address - Phone:615-388-8469
Mailing Address - Fax:
Practice Address - Street 1:346 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-7512
Practice Address - Country:US
Practice Address - Phone:270-222-3851
Practice Address - Fax:833-673-0436
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1118363A00000X
KYPA1117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508213Medicaid
TN1508213Medicaid
TNQ06279Medicare UPIN
KY0666111Medicare PIN
KY0666013Medicare PIN
KY0381114Medicare PIN
KY0381114Medicare PIN