Provider Demographics
NPI:1043220148
Name:MAHON, KEVIN PATRICK (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:MAHON
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4896 S BRIGHT ANGEL TRL
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-8369
Mailing Address - Country:US
Mailing Address - Phone:928-380-1911
Mailing Address - Fax:
Practice Address - Street 1:4896 S BRIGHT ANGEL TRL
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86005-8369
Practice Address - Country:US
Practice Address - Phone:928-380-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
AZ16292251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ82454Medicare ID - Type Unspecified