Healthcare Provider Details

I. General information

NPI: 1891752614
Provider Name (Legal Business Name): MARY ANN H TREPHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ANN HANES MD

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD
NORTHRIDGE CA
91328
US

IV. Provider business mailing address

PO BOX 4675
THOUSAND OAKS CA
91359-1675
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG85040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: