Provider Demographics
NPI:1952150211
Name:MULLIS, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MULLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 W DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-6310
Mailing Address - Country:US
Mailing Address - Phone:941-716-4788
Mailing Address - Fax:
Practice Address - Street 1:1950 ARLINGTON ST STE 203
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3516
Practice Address - Country:US
Practice Address - Phone:941-379-6331
Practice Address - Fax:941-379-5443
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9119173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program