Basic Information
| Provider Information | |||||||||
| NPI: | 1366521213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUDD | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MMSC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4035 MAYBREEZE RD | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300662733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705175918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 531 ROSELANE ST NW | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300606913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707940477 | ||||||||
| FaxNumber: | 7707943108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 001836 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.