Healthcare Provider Details

I. General information

NPI: 1174766109
Provider Name (Legal Business Name): NICOLE SARAH MCMAHON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

IV. Provider business mailing address

1 ELK RIDGE LN
SOUTHERN PINES NC
28387-5173
US

V. Phone/Fax

Practice location:
  • Phone: 504-391-7585
  • Fax:
Mailing address:
  • Phone: 504-491-0423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.203974
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014-00237
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1882968
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: