Basic Information
| Provider Information | |||||||||
| NPI: | 1366407348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCMULLAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 S HARBOR CITY BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217255050 | ||||||||
| FaxNumber: | 3217259100 | ||||||||
| Practice Location | |||||||||
| Address1: | 8057 SPYGLASS HILL RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214353500 | ||||||||
| FaxNumber: | 3214353501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 02/06/2015 | ||||||||
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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 | 363A00000X | PA9100940 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 290844100 | 05 | FL | MEDICAID |