Provider Demographics
NPI:1144242389
Name:MAHAN, ALTA DAWNE (DC)
Entity Type:Individual
Prefix:
First Name:ALTA
Middle Name:DAWNE
Last Name:MAHAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ALTA
Other - Middle Name:DAWNE
Other - Last Name:ANTYPOWICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:20119 S PRAIRIE RD E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7935
Mailing Address - Country:US
Mailing Address - Phone:253-862-1555
Mailing Address - Fax:253-862-1557
Practice Address - Street 1:20119 S PRAIRIE RD E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7935
Practice Address - Country:US
Practice Address - Phone:253-862-1555
Practice Address - Fax:253-862-1557
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00033625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8808339Medicare PIN