Healthcare Provider Details

I. General information

NPI: 1134791445
Provider Name (Legal Business Name): SHANE M MCMAHON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 08/26/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL UNIT #15281 BLDG. 3031, CAMP HUMPHREYS
APO AP
96271
US

IV. Provider business mailing address

PSC 444 BOX 2288
APO AP
96297-0023
US

V. Phone/Fax

Practice location:
  • Phone: 727-455-4207
  • Fax:
Mailing address:
  • Phone: 727-455-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS022933
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: