Provider Demographics
NPI:1871515601
Name:O'CONNOR, MARY JEAN (NP)
Entity type:Individual
Prefix:
First Name:MARY JEAN
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:5700 CANOGA AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6579
Mailing Address - Country:US
Mailing Address - Phone:818-595-8100
Mailing Address - Fax:818-595-8206
Practice Address - Street 1:364 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2322
Practice Address - Country:US
Practice Address - Phone:949-557-0610
Practice Address - Fax:949-557-0611
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-03-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA7588363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ68537Medicare UPIN