Provider Demographics
NPI:1891961215
Name:MAHAN, RACHAEL (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:RACHAEL
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 BRIARGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7804
Mailing Address - Country:US
Mailing Address - Phone:719-305-9060
Mailing Address - Fax:719-305-9061
Practice Address - Street 1:4125 BRIARGATE PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7804
Practice Address - Country:US
Practice Address - Phone:719-305-9060
Practice Address - Fax:719-305-9061
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.000369363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical