Provider Demographics
NPI:1215019575
Name:OHARA, MAUREEN (PAC)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:OHARA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4576 TWINING STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-2033
Mailing Address - Country:US
Mailing Address - Phone:323-222-6454
Mailing Address - Fax:
Practice Address - Street 1:7601 EAST IMPERIAL HWY
Practice Address - Street 2:ROOM HB145
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242
Practice Address - Country:US
Practice Address - Phone:562-401-7225
Practice Address - Fax:562-401-7615
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAM052014OtherCOUNTY OF LOS ANGELES RANCHO LOS AMIGOS
CABH535ZMedicare PIN