Provider Demographics
NPI:1801434873
Name:MCMAHON, BRETT ALAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:ALAN
Last Name:MCMAHON
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29944 MACINTOSH LN
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-8906
Mailing Address - Country:US
Mailing Address - Phone:248-763-0911
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704293922OtherNURSE PRACTITIONER CERTIFICATION