Provider Demographics
NPI:1497084396
Name:MAHONY, JOHN P (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:MAHONY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PASEO DEL PUEBLO SUR STE C
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5328
Mailing Address - Country:US
Mailing Address - Phone:575-758-1414
Mailing Address - Fax:
Practice Address - Street 1:330 PASEO DEL PUEBLO SUR STE C
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5328
Practice Address - Country:US
Practice Address - Phone:575-758-1414
Practice Address - Fax:575-758-1474
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant