Provider Demographics
NPI:1790231967
Name:STEVENS, MARA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:L
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W PACIFIC COAST HWY APT 239
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1894
Mailing Address - Country:US
Mailing Address - Phone:740-503-5609
Mailing Address - Fax:
Practice Address - Street 1:3851 KATELLA AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3487
Practice Address - Country:US
Practice Address - Phone:562-430-4138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant