Provider Demographics
NPI:1295840585
Name:MAHONEY, JEFFREY LEE (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1664 BERKFORD CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1707
Mailing Address - Country:US
Mailing Address - Phone:770-234-9452
Mailing Address - Fax:
Practice Address - Street 1:501 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1415
Practice Address - Country:US
Practice Address - Phone:706-291-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003963367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I320188Medicare PIN