Provider Demographics
NPI:1235143348
Name:MCMAHON, PETER E (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:MCMAHON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:PETE
Other - Middle Name:E
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-991-2561
Mailing Address - Fax:920-560-1147
Practice Address - Street 1:2223 LIME KILN RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-965-4715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40298300Medicaid
WI07028-0259Medicare PIN
WI40298300Medicaid