Basic Information
| Provider Information | |||||||||
| NPI: | 1205912649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLIN | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | KRISTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENSEN | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | KRISTIN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5900 S LAKE DR | ||||||||
| Address2: | |||||||||
| City: | CUDAHY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531103171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5900 S LAKE DR | ||||||||
| Address2: | |||||||||
| City: | CUDAHY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531103171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496588 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 49720020 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005 | 01 | WI | BCBS | OTHER |