Basic Information
| Provider Information | |||||||||
| NPI: | 1245292085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHAN | ||||||||
| FirstName: | MARCELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2717 | ||||||||
| Address2: | |||||||||
| City: | MCKINLEYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955192717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074998781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 DOLBEER ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072694250 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G71860 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | G078160 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 00G718600 | 05 | CA | MEDICAID |