1245755024 NPI number — MRS. KELLY TUNBERG MCMAHON PA-C

Table of content: MRS. KELLY TUNBERG MCMAHON PA-C (NPI 1245755024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245755024 NPI number — MRS. KELLY TUNBERG MCMAHON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMAHON
Provider First Name:
KELLY
Provider Middle Name:
TUNBERG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TUNBERG
Provider Other First Name:
KELLY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245755024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 EAST LAS OLAS BLVD
Provider Second Line Business Mailing Address:
STE. # 110
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-765-3005
Provider Business Mailing Address Fax Number:
317-814-2140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 EAST LAS OLAS BLVD
Provider Second Line Business Practice Location Address:
STE. # 110
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-765-3005
Provider Business Practice Location Address Fax Number:
317-814-2140
Provider Enumeration Date:
08/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  100002216A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9112263 . This is a "FL STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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