1699777359 NPI number — JEROLD LEE MULLINS CRNA

Table of content: JEROLD LEE MULLINS CRNA (NPI 1699777359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699777359 NPI number — JEROLD LEE MULLINS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLINS
Provider First Name:
JEROLD
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699777359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12448 296TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55371-9138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8990 SPRINGBROOK DR NW
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-5850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-398-0099
Provider Business Practice Location Address Fax Number:
763-398-0124
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R 082378-2 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 367542400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268T6MU . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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