Provider Demographics
NPI:1053311654
Name:MAHON, PATRICIA NADJA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:NADJA
Last Name:MAHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:NADJA
Other - Last Name:MAHON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:225 SHADOW VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76273-7136
Mailing Address - Country:US
Mailing Address - Phone:903-564-3985
Mailing Address - Fax:
Practice Address - Street 1:315 N TRAVIS ST
Practice Address - Street 2:SUITE B-1
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-0028
Practice Address - Country:US
Practice Address - Phone:903-361-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2 1254103TC0700X
TX431493363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1601973Medicaid
TX0321382Medicaid
TX0321382Medicaid
TX00679PMedicare ID - Type UnspecifiedNURSE PRACTITIONER-CERTIF
TXR56471Medicare UPIN