Basic Information
| Provider Information | |||||||||
| NPI: | 1801434873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMAHON | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29944 MACINTOSH LN | ||||||||
| Address2: | |||||||||
| City: | NEW HUDSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481658906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487630911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6071 W OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482352624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139663300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2019 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704293922 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4704293922 | 01 | MI | NURSE PRACTITIONER CERTIFICATION | OTHER |