Provider Demographics
NPI:1790494052
Name:MCMAHON, PAUL LYLE JR (PTA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LYLE
Last Name:MCMAHON
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 E CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1014
Mailing Address - Country:US
Mailing Address - Phone:515-320-5474
Mailing Address - Fax:
Practice Address - Street 1:1110 W OMAHA ST # 3
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-8097
Practice Address - Country:US
Practice Address - Phone:605-721-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0544225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant