Provider Demographics
NPI:1245755024
Name:MCMAHON, KELLY TUNBERG (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:TUNBERG
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:TUNBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:350 EAST LAS OLAS BLVD
Mailing Address - Street 2:STE. # 110
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301
Mailing Address - Country:US
Mailing Address - Phone:954-765-3005
Mailing Address - Fax:317-814-2140
Practice Address - Street 1:350 EAST LAS OLAS BLVD
Practice Address - Street 2:STE. # 110
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301
Practice Address - Country:US
Practice Address - Phone:954-765-3005
Practice Address - Fax:317-814-2140
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN100002216A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9112263OtherFL STATE LICENSE