Healthcare Provider Details

I. General information

NPI: 1598658759
Provider Name (Legal Business Name): SAMUEL KEITH MAHON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-1202
US

IV. Provider business mailing address

PO BOX 100288
GAINESVILLE FL
32610-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-9079
  • Fax: 352-273-8889
Mailing address:
  • Phone: 352-273-9079
  • Fax: 352-273-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119819
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: