Healthcare Provider Details

I. General information

NPI: 1902852155
Provider Name (Legal Business Name): MARA BETH COYNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER SUITE 200
GLENDALE CA
91206-4071
US

IV. Provider business mailing address

27426 CHERRY CREEK DR
VALENCIA CA
91354-2056
US

V. Phone/Fax

Practice location:
  • Phone: 818-246-8974
  • Fax: 818-246-7673
Mailing address:
  • Phone: 661-297-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPT-18312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: