Provider Demographics
NPI:1609509991
Name:MAHAN, PAMELA J (PA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:MAHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 ROYAL TERN RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2486
Mailing Address - Country:US
Mailing Address - Phone:904-465-4920
Mailing Address - Fax:
Practice Address - Street 1:150 PROFESSIONAL DR STE 700
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-7233
Practice Address - Country:US
Practice Address - Phone:904-273-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2504363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical