MEDICARE: JOANN MAHAN APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WE0003X	Emergency Registered Nurse	R43284	AR
2	363LF0000X	Family Nurse Practitioner	A004261	AR

General Provider Information

NPI Number	:	1104225317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANN MAHAN APRN

Provider Business Mailing Address
First Line	:	3416 OLD GREENWOOD RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5462
Country	:	US
Telephone Number	:	479-242-2888
Fax Number	:	479-242-2889

Provider Business Practice Location Address
First Line	:	3416 OLD GREENWOOD RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5462
Country	:	US
Telephone Number	:	479-242-2888
Fax Number	:	479-242-2889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/27/2015

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