Healthcare Provider Details

I. General information

NPI: 1841263365
Provider Name (Legal Business Name): GLENN ANDREW MAHONEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8910 VERNON ROAD
LAKE STEVENS WA
98258
US

IV. Provider business mailing address

3901 HOYT AVENUE
EVERETT WA
98201
US

V. Phone/Fax

Practice location:
  • Phone: 425-335-0966
  • Fax: 425-335-5145
Mailing address:
  • Phone: 425-339-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC942
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60042438
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12451
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: