Provider Demographics
NPI:1841263365
Name:MAHONEY, GLENN ANDREW (PAC)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ANDREW
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 HOYT AVENUE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201
Mailing Address - Country:US
Mailing Address - Phone:425-339-5462
Mailing Address - Fax:
Practice Address - Street 1:8910 VERNON ROAD
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258
Practice Address - Country:US
Practice Address - Phone:425-335-0966
Practice Address - Fax:425-335-5145
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPAC942363AM0700X
WAPA60042438363AM0700X
GA12451363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507753Medicaid
NV100507754Medicaid
NV100507753Medicaid
Q59035Medicare UPIN