Provider Demographics
NPI:1922193192
Name:MAHAN, KAAREN L (PA-C)
Entity type:Individual
Prefix:
First Name:KAAREN
Middle Name:L
Last Name:MAHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KAAREN
Other - Middle Name:L
Other - Last Name:MAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAHAN-RISKA
Mailing Address - Street 1:2920 CARLISLE BLVD NE BLDG B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2867
Mailing Address - Country:US
Mailing Address - Phone:575-973-2364
Mailing Address - Fax:505-944-9751
Practice Address - Street 1:2920 CARLISLE BLVD NE BLDG B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2867
Practice Address - Country:US
Practice Address - Phone:575-973-2364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0011207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90352891Medicaid
NM348510906Medicare PIN
348510906Medicare ID - Type Unspecified
NM90352891Medicaid
NM348510907Medicare PIN