Provider Demographics
NPI:1386470151
Name:MCMAHAN, SHAWN SAMUEL
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:SAMUEL
Last Name:MCMAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1306
Mailing Address - Country:US
Mailing Address - Phone:813-842-1775
Mailing Address - Fax:
Practice Address - Street 1:3121 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1306
Practice Address - Country:US
Practice Address - Phone:614-869-2002
Practice Address - Fax:614-792-6240
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005509175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist