Provider Demographics
NPI:1013786128
Name:MCMAHAN, ELIZABETH REVERE (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:REVERE
Last Name:MCMAHAN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 S SAGINAW RD STE E
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8206
Mailing Address - Country:US
Mailing Address - Phone:810-695-4000
Mailing Address - Fax:
Practice Address - Street 1:9450 S SAGINAW RD STE E
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8206
Practice Address - Country:US
Practice Address - Phone:810-695-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318459363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health