Provider Demographics
NPI:1790800472
Name:MAHAN, EDWARD P (PA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
Last Name:MAHAN
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:535 MAXHAM RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-5541
Mailing Address - Country:US
Mailing Address - Phone:770-948-5409
Mailing Address - Fax:770-948-6774
Practice Address - Street 1:3820 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1110
Practice Address - Country:US
Practice Address - Phone:770-948-6041
Practice Address - Fax:770-819-2987
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA003847363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP05420Medicare UPIN