Provider Demographics
NPI:1578681219
Name:MCMAHAN, MARY JANE (LPTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:MCMAHAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:COWLES
Other - Last Name:MCMAHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2838 ARCHER ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6512
Mailing Address - Country:US
Mailing Address - Phone:540-389-6258
Mailing Address - Fax:
Practice Address - Street 1:1127 PERSINGER RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3829
Practice Address - Country:US
Practice Address - Phone:540-343-1691
Practice Address - Fax:540-343-1696
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000933225200000X
FLPTA883225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant