Provider Demographics
NPI:1033496476
Name:MAHAN, TARA JANEN (PA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JANEN
Last Name:MAHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 GRAND CENTRAL AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4366
Mailing Address - Country:US
Mailing Address - Phone:410-581-1600
Mailing Address - Fax:
Practice Address - Street 1:950 HARRY S TRUMAN DR N STE 500
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5486
Practice Address - Country:US
Practice Address - Phone:301-321-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
607156012OtherDEPT OF LABOR
607156014OtherBLACK LUNG
607156012OtherDEPT OF LABOR
231856Y5ZMedicare PIN