Healthcare Provider Details

I. General information

NPI: 1801417712
Provider Name (Legal Business Name): DEANDRA MAHON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E 32ND ST
SILVER CITY NM
88061-7287
US

IV. Provider business mailing address

1523 VISTA DEL LAGO BLVD
DUNDEE FL
33838-4429
US

V. Phone/Fax

Practice location:
  • Phone: 575-538-2981
  • Fax:
Mailing address:
  • Phone: 954-770-1217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0046
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: