Provider Demographics
NPI:1184068298
Name:MAHAN, KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 LEEWARD WAY
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-672-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN62879207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty