Basic Information
| Provider Information | |||||||||
| NPI: | 1033496476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHAN | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | JANEN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64916 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816469 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
| FaxNumber: | 4434811687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2011 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C04638 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 607156012 | 01 | DEPT OF LABOR | OTHER | 607156014 | 01 | BLACK LUNG | OTHER |