Healthcare Provider Details

I. General information

NPI: 1417034877
Provider Name (Legal Business Name): MARY LYNN MORAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/11/2025
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2973 WOODSIDE RD
WOODSIDE CA
94062-2443
US

IV. Provider business mailing address

600A FRAZIER DR STE 120
FRANKLIN TN
37067-4670
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-0565
  • Fax: 650-851-0520
Mailing address:
  • Phone: 615-224-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberG-076828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: