Healthcare Provider Details

I. General information

NPI: 1578681219
Provider Name (Legal Business Name): MARY JANE MCMAHAN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY COWLES MCMAHAN

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 PERSINGER RD SW
ROANOKE VA
24015-3829
US

IV. Provider business mailing address

2838 ARCHER ST
SALEM VA
24153-6512
US

V. Phone/Fax

Practice location:
  • Phone: 540-343-1691
  • Fax: 540-343-1696
Mailing address:
  • Phone: 540-389-6258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306000933
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA883
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: