Provider Demographics
NPI:1942973474
Name:MAHAN, MAEGAN A
Entity Type:Individual
Prefix:
First Name:MAEGAN
Middle Name:A
Last Name:MAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-0108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:ME
Practice Address - Zip Code:04930-1333
Practice Address - Country:US
Practice Address - Phone:207-907-0492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECNP211256Medicaid