Provider Demographics
NPI:1649888751
Name:MCMAHAN, WILLIE EUGENE JR (PTA)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:EUGENE
Last Name:MCMAHAN
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 SFC 858
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:AR
Mailing Address - Zip Code:72372-8431
Mailing Address - Country:US
Mailing Address - Phone:870-261-8910
Mailing Address - Fax:
Practice Address - Street 1:1871 FALLS BLVD N
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-4026
Practice Address - Country:US
Practice Address - Phone:870-261-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2756225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant