Provider Demographics
NPI:1043291115
Name:MULLEN, JANA RAQUEL (MD)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:RAQUEL
Last Name:MULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:PAAUILO
Mailing Address - State:HI
Mailing Address - Zip Code:96776-0485
Mailing Address - Country:US
Mailing Address - Phone:808-776-1704
Mailing Address - Fax:
Practice Address - Street 1:43-2026 PAAUILO MAUKA RD
Practice Address - Street 2:
Practice Address - City:PAAUILO
Practice Address - State:HI
Practice Address - Zip Code:96776
Practice Address - Country:US
Practice Address - Phone:808-776-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60665668208000000X, 208000000X
NC9601680208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1043291115Medicaid
WAP01702028OtherRR PTAN WVH
WAG8955641, G8955642Medicare PIN