Provider Demographics
NPI:1811960099
Name:MCNULTY, MICHAEL S (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22928 EAGLES WATCH DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-4787
Mailing Address - Country:US
Mailing Address - Phone:813-929-0733
Mailing Address - Fax:813-903-4812
Practice Address - Street 1:22928 EAGLES WATCH DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-4787
Practice Address - Country:US
Practice Address - Phone:813-929-0733
Practice Address - Fax:813-903-4812
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2016-02-24
Deactivation Date:2016-02-01
Deactivation Code:
Reactivation Date:2016-02-24
Provider Licenses
StateLicense IDTaxonomies
PAMA0011803L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA0011803LOtherLICENSE