Provider Demographics
NPI:1891861365
Name:MAHAN, DAVID MICHAEL (PA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:MAHAN
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 1:2401 E STREET NW
Mailing Address - Street 2:M-MED-QI, SA-1
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0001
Mailing Address - Country:US
Mailing Address - Phone:202-663-2453
Mailing Address - Fax:202-663-3247
Practice Address - Street 1:2410 NDJAMENA PL
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20189-2410
Practice Address - Country:US
Practice Address - Phone:202-663-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103982363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical