Provider Demographics
NPI:1629072442
Name:MCMAHON, MICHAEL (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MCMAHON
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 1:1062 BARNES RD
Mailing Address - Street 2:STE 300
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2576
Mailing Address - Country:US
Mailing Address - Phone:203-265-9831
Mailing Address - Fax:203-265-2977
Practice Address - Street 1:1062 BARNES RD
Practice Address - Street 2:STE 300
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2576
Practice Address - Country:US
Practice Address - Phone:203-265-9831
Practice Address - Fax:203-265-2977
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000844363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000360Medicare PIN
S66524Medicare UPIN