Provider Demographics
NPI:1245279140
Name:MAHAN, PAULA B (PA)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:B
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9696
Mailing Address - Fax:239-343-9707
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 206
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9696
Practice Address - Fax:239-343-9707
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004614363A00000X
FLPA9110244363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGLTF8OtherBCBS
FL020397700Medicaid
FLIX801ZOtherMEDICARE
GA003109932BMedicaid