Provider Demographics
NPI:1417034877
Name:MORAN, MARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY LYNN
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600A FRAZIER DR STE 120
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-4670
Mailing Address - Country:US
Mailing Address - Phone:615-224-8387
Mailing Address - Fax:
Practice Address - Street 1:2973 WOODSIDE RD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-2443
Practice Address - Country:US
Practice Address - Phone:650-851-0565
Practice Address - Fax:650-851-0520
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-076828207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G768280Medicaid
CAE69463Medicare UPIN
CA00G768280Medicaid