Healthcare Provider Details

I. General information

NPI: 1669129441
Provider Name (Legal Business Name): ANNA RYAN HEPBURN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SUPERIOR AVE STE 330
NEWPORT BEACH CA
92663-3658
US

IV. Provider business mailing address

22062 COSALA
MISSION VIEJO CA
92691-1223
US

V. Phone/Fax

Practice location:
  • Phone: 949-646-2800
  • Fax:
Mailing address:
  • Phone: 912-585-3128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: