Active NPI
Kelly Tunberg McMahon, PA-C
- Physician Assistant
- Fort Lauderdale, FL
National Provider Identifier
1245755024
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 100002216A
- Practice address
- 350 East Las Olas Blvd
Ste. # 110
Fort Lauderdale, FL 33301 - Phone
- (954) 765-3005
- Fax
- (317) 814-2140
- NPI assigned
- Aug 14, 2017
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 100002216A | IN | Primary |
Addresses
Primary practice location
350 East Las Olas Blvd
Ste. # 110
Fort Lauderdale, FL 33301
Mailing address
350 East Las Olas Blvd
Ste. # 110
Fort Lauderdale, FL 33301
Phone (954) 765-3005
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9112263 | Other | FL | FL STATE LICENSE |
Other names 1
- Ms. Kelly Marie Tunberg
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 100002216A | IN | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Shino Bay Cosmetic Dermatology & Laser Institute LLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dermatology Physician
- Ft Lauderdale, FL
- NPI 1164690582
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1502668800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1606867200000",
"number": "1245755024",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "350 EAST LAS OLAS BLVD",
"address_2": "STE. # 110",
"city": "FORT LAUDERDALE",
"state": "FL",
"postal_code": "33301",
"telephone_number": "954-765-3005",
"fax_number": "317-814-2140"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "350 EAST LAS OLAS BLVD",
"address_2": "STE. # 110",
"city": "FORT LAUDERDALE",
"state": "FL",
"postal_code": "33301",
"telephone_number": "954-765-3005",
"fax_number": "317-814-2140"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MCMAHON",
"first_name": "KELLY",
"middle_name": "TUNBERG",
"name_prefix": "Mrs.",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2017-08-14",
"last_updated": "2020-12-02",
"certification_date": "2020-12-02",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "IN",
"license": "100002216A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FL STATE LICENSE",
"identifier": "9112263",
"state": "FL"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "KELLY",
"last_name": "TUNBERG",
"middle_name": "MARIE",
"prefix": "MS.",
"credential": "PA-C",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Fort Lauderdale, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.