Basic Information
| Provider Information | |||||||||
| NPI: | 1144255373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLEN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 SMYTH RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031044098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 718 SMYTH RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031044098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0507 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1861558645 | 01 | NH | NSC PROVIDER LOCATION # | OTHER | 1932256914 | 01 | NH | NSC PROVIDER LOCATION # | OTHER | 1841320207 | 01 | NH | NSC PROVIDER LOCATION # | OTHER | 1922164797 | 01 | NH | NSC PROVIDER LOCATION # | OTHER | 1881772242 | 01 | NH | NSC PROVIDER LOCATION # | OTHER | 30333016 | 05 | NH | MEDICAID | 1801952692 | 01 | NSC PROVIDER LOCATION # | OTHER |