Healthcare Provider Details

I. General information

NPI: 1811635865
Provider Name (Legal Business Name): ELIZABETH LEIGH MCMAHON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 VAN DYKE RD
LUTZ FL
33558-4880
US

IV. Provider business mailing address

4651 VAN DYKE RD
LUTZ FL
33558-4880
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-1786
  • Fax: 813-321-1787
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: