Provider Demographics
NPI:1144400771
Name:OKIMOTO, MARY M (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:OKIMOTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-543-5577
Mailing Address - Fax:805-595-3231
Practice Address - Street 1:715 TANK FARM ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7068
Practice Address - Country:US
Practice Address - Phone:805-543-5577
Practice Address - Fax:805-595-3231
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17444364SX0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0204XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology, Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB242811OtherMEDICARE ID