Basic Information
| Provider Information | |||||||||
| NPI: | 1174766109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCMAHON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | SARAH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ELK RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | SOUTHERN PINES | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283875173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044910423 | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043917585 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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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 | 208000000X | MD.203974 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2014-00237 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1882968 | 05 | LA | MEDICAID |