1821069964 NPI number — MRS. DEBORAH LYNN MULLINAX PA-C

Table of content: MRS. DEBORAH LYNN MULLINAX PA-C (NPI 1821069964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821069964 NPI number — MRS. DEBORAH LYNN MULLINAX PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLINAX
Provider First Name:
DEBORAH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1821069964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2335 PAPAGO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERIDAN
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82801-5835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-674-6093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
916 JACKSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERIDAN
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82801-2708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-672-6451
Provider Business Practice Location Address Fax Number:
307-672-1704
Provider Enumeration Date:
01/27/2006

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: 363AM0700X , with the licence number:  344 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00941001 . This is a "BCBS GROUP" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 830245718-13 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7705130 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000405665 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 313672 . This is a "BCBS INDIV" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 100048900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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