Basic Information
| Provider Information | |||||||||
| NPI: | 1114366325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULHEARN | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | REBEKAH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128258 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373128328 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2013 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.200625 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2345567 | 05 | LA | MEDICAID |