Provider Demographics
NPI:1780053777
Name:MCMULLIN, MICHAEL DAVID (LMP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:MCMULLIN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21707 103RD AVENUE CT E STE B201
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-8308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21707 103RD AVENUE CT E STE B201
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8308
Practice Address - Country:US
Practice Address - Phone:406-212-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-19
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60597525225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist