Provider Demographics
NPI:1619747920
Name:MCMAHAN, JUSTIN WILSON
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WILSON
Last Name:MCMAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PHILIP ST
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-2335
Mailing Address - Country:US
Mailing Address - Phone:864-828-3692
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:803-216-3763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC254500163WC0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine