Basic Information
| Provider Information | |||||||||
| NPI: | 1225656085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULLANEY | ||||||||
| FirstName: | KAMERON | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6520 FORT CAROLINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322772044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047453618 | ||||||||
| FaxNumber: | 9047224271 | ||||||||
| Practice Location | |||||||||
| Address1: | 6484 FORT CAROLINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322772042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047447300 | ||||||||
| FaxNumber: | 9047224271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA9113642 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 390200000X | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA9113642 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.