Basic Information
| Provider Information | |||||||||
| NPI: | 1689221210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULLEN | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 427 BEACH 122ND ST | ||||||||
| Address2: | |||||||||
| City: | ROCKAWAY PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116941826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3477528244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100654870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127465026 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2019 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | F344194-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | MM5404152 | 01 | NY | DEA REGISTRATION NUMBER | OTHER |