Basic Information
| Provider Information | |||||||||
| NPI: | 1124461116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIN | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 PRESIDENTIAL PLAZA | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644357 | ||||||||
| FaxNumber: | 3154642030 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLAZA | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644357 | ||||||||
| FaxNumber: | 3154642030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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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 | 363LP0200X | 382370 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 03583951 | 05 | NY | MEDICAID |