Provider Demographics
NPI:1609126325
Name:MULLEN, ELIZABETH CATHERINE (PA-C)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:CATHERINE
Last Name:MULLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:CATHERINE
Other - Last Name:WILLISTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 KINGS HIGHWAY SOUTH
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617
Mailing Address - Country:US
Mailing Address - Phone:585-922-1304
Mailing Address - Fax:
Practice Address - Street 1:4 COULTER RD STE 1630
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY0160341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant